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HEALTH SCIENCES LIBRARY
OF THE
UNIVERSITY OF NORTH CAROLINA
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Digitized by tlie Internet Arcliive
in 2009 witli funding from
Nortli Carolina History of Health Digital Collection, an LSTA-funded NC ECHO digitization grant project
http://www.archive.org/details/transactionsofme67medi
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TRANSACTIONS
OF THE
MEDICAL SOCIETY
OF THE
STATE OF NORTH CAROLINA
SIXTY-SEVENTH ANNUAL MEETING
HELD AT
CHARLOTTE, NORTH CAROLINA
APRIL 20, 21,22, 1920
DIVISION OF^ HEALTH SCIENCES LIBRARY
President, DR. C. V. REYNOLDS, Asheville, N. C.
Secretary, DR. BENJ. K. HAYS, Oxford, N. C.
Reporter, MRS. S. W. SUMMERS, Raleigh, N. C.
COMMITTEE ON PUBLICATION
Dr. p. p. McCain Sanatorium
Dr. C. a. Julian Thomasville
Dr. W. L. Dunn Asheville
"It is understood that the Society is not to be considered as endorsing all
the views and opinions of authors of papers published in the Transactions
of the Society." — Extract from By-Laws, chapter lo, section 8.
CONTENTS
See Index, Page 402 et seq.
Carl V. Reynolds, M. D Frontispiece
Committee on Publication iv
Early History of North Carolina Medical Society viii
Roster of Officers of Society, 1849 to 1920 ix
Past Members Board of Medical Examiners xii
Roster of State Board Health, 1877 to 1919 xiii
Status of Membership by Counties, 1907-1920 xv
Honorary Fellows, North Carolina Medical Society xvii
Honorary Members, North Carolina Medical Society xix
Officers of the Society, 1919-1920 xx
Officers of the Society, 1920-1921 xx
Councilors, 1919-1922 xx
Chairmen of Sections, 1921 Session xx
Program, General Sessions xxi
Members of State Board of Health xxii
Executive Staff of State Board of Health xxii
Order of Business xxii
Section Meetings xxv
Foreword xxxi
Page
Opening Exercises 1
Invocation — Dr. Bunyan McLeod 1
Welcome to the City of Charlotte — Hon. F. R. McNinch, Mayor 1
Welcome to Mecklenburg County — Hon. Cameron Morrison 3
Welcome from Mecklenburg County Medical Society — Dr. C. M. Strong 4
Response to Addresses of Welcome — Dr. Thompson Eraser 6
Address of the President — Medical Legislation — C. V. Reynolds 7
Practice of Medicine 18-87
Report of Twenty-Five Autopsies on Influenza Pneumonia — Dr. James
M. Bullitt 18
A Case of Eventration of the Diaphram — W. M. Allen, M. D 22
X-Ray Findings in the Lung Following Influenza, Tuberculous and Oth-
erwise — Dr. R. P. Noble 25
Preliminary Report on a Study of the Goetsch Test — Dr. R. McBrayer__ 27
Essential Hypertension — Dr. R. F. Leinbach 32
Mechanism of Convulsive Movements of the Orbicularies and Face, and
the Manner of Their Removal — Dr. Tom A. Williams 37
Anaemia, with the Report of Two Cases, One Secondary and the Other
Primary — Dr. K. C. Moore 40
Arterial Tension and Its Clinical Manifestations — Dr. Charles H. Peete 44
VI CONTENTS
Page
Toxic Arthralgia — Dr. O. Edwin Finch 46
Sjonptomatology of Typhoid Fever — Dr. P. R. Hardee 52
Some Facts, Old and New, Concerning the Heart and the Pulse — Dr. Hu-
bert Benbury Haywood, Jr : 55
A Review of the Recent Work on Amoebic Dysentery — Dr. William Allan 63
The Modern Therapeutic Value of Digitalis — Dr. Joseph A. Speed 67
Radium in the Treatment of Skin Cancer — Dr. W. D. James 71
Double Choked Discs — Operation, with Recovery of Vision — Henry L.
Sloan, M. D 74
Different Forms of Food Adulteration — W. M. Allen, 76
Blood Chemistry in Nephritis — Dr. W. M. Copridge 83
Surgery i 88-133
Acute Pancreatitis Resembling Acute Intestinal Obstruction, Report of
Cases — Eugene B. Glenn 88
Saving Suppurating Incisions — Hubert A. Royster, M. D 94
Goiter — Addison Brenizer, M. D 98
Inguinal Hernia — Dr. J, T. Burrus 107
Some Problems Met with in Gall-Bladder Surgery — Dr. J. W. Tankers-
ley 109
Treatment of Infected Bone Cavities — Drs. D. W. and Ernest S. Bulluck
and R. H. Davis 112
Closure of Belly Wall Based on the Healing Power of Tissue — Henry F.
Long, M. D 115
Hyperthropic Stenosis of the Pylorus — Dr. E. T. Dickinson 119
End Results of One Hundred Cases of Cancer of Uterus — Dr. J. A. Wil-
liams . 123
Subphrenic Abscess — George Vv^'m. Pressley, M. D 124
Ascariasis As a Surgical Complication — Henry Norris, M. D 127
The Surgeon and Roentgenology — Dr. R. H. Lafferty 129
A Troublesome Complication of Gonorrhoea, Its Treatment — Hamilton
W. McKay, M. D 130
Gynecology and Obstetrics : 134-150
Some Phases of Obstetrics — Dr. J. M. Manning 134
Concerning the Disease of the Cervix Uteri — Dr. Foy Roberson 137
Cesarean Section in Eclampsia — C. A. Woodard 139
Ovarian Tumors — Dr. John B. Nicholson 141
The Termination of Pregnancy for Therapeutic Reasons — Dr. F. Webb
Griffith 144
Eye, Ear, Nose and Throat 151-162
What Constitutes Good Tonsil Surgery — John W. MacConnell, M. D 151
Conservatism in Treating Foci of Infection — J. G. Murphy, M. D 155
The Relation of Public Health Work to the Business Interest of the Eye,
Nose and Throat Specialists of North Carolina — G. M. Cooper, M. D. 156
CONTENTS VU
Page
Pediatrics 163-212
The Importance of Lumbar Puncture in Intra-Cranial Hemorrhage of
the New-Bora — Dr. J. Buren Sidbury 163
Acidosis— Dr. L. W. Elias I'^S
Infection of the New-Born— Dr. Yates W. Faison 180
Simplified Feeding and the Breast — Frank Howard Richardson, M. D.__ 186
Laryngeal Stenosis— L. Y. Royster, M. D 203
Public Health and Education 213-267
Importance of a City Tuberculosis Sanatorium — Dr. R. L. Carlton 213
City Abattoir and Meat Inspection — Dr. R. L. Carlton 214
Remedial Conditions in School Children— Margery J. Lord, M. D 217
The State Plan for Securing Medical and Dental Care of School Chil-
dren— G. M. Cooper, M. D 224
Our Tuberculosis Problems — Dr. B. O. Edwards 227
Some of the Things Necessary to the Eradication of Tuberculosis — Dr.
E. Brooks 231
Venereal Diseases — A Public Problem — Millard Knowlton, M. D 236
The State Program for Venereal Disease Control — Millard Knowlton_- 240
An Ideal Venereal Disease Clinic Organization — Dr. Raymond Thompson 244
The Importance of Laboratory Facilities for a Venereal Disease Clinic —
Dr. L. C. Todd 248
Gonorrhoeal .Complications in Their Relation to Infectivity — Dr. A.
F. Toole 250
The Diagnosis and Treatment of Syphilis — Dr. C. 0. Abernethy 252
Central Nervous System Syphilis ;Its Incidence and Treatment — Joseph
A. Elliott, M. D 255
Report of Board of Examiners — H. A. Royster, Secretary 262
Nominations for Members Board of Medical Examiners 268
Election of Members of Nurses' Examining Board 270
State Medicine— Dr.W. S. Rankin 272
Proceedings of the House of Delegates 289
Report of Secretary-Treasurer 290
Report of Committee on Regulation of Work of Midwives 292
Memorial Exercises 297
Annual Report of Secretary of State Board of Health 321
Official List North Carolina Officers of Officers' Medical Corps, U. S. A. 333
Alphabetical List Members of Medical Society, with P. O, Addresses — 334
Roster of Members for 1921, by Counties 350
Transactions of North Carolina Health Officers' Association 415
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XIU
ROSTER OF MEMBERS NORTH CAROLINA STATE BOARD OF HEALTH
FROM ORGANIZATION IN 1877 TO 1919
Name
S. S. Satchwell, M.D., President
Thomas F. Wood, M.D., Secretary
Joseph Graham, M.D
Charles Duffy, Jr., M.D
Peter E. Hines, M.D
George A. Foote, M.D
S. S. Satchwell, M.D., President
Thomas F. Wood, M.D., Secretary
Charles J. O'Hagan.M. D., President.^
George A. Foote, M.D
Marcellus Whitehead, M.D
R. L. Payne, M.D
H. G. Woodfin, M.D
A. R. Ledeux, Chemist
WiPiam Cain, Civil Engineer
R. L. Payne, M.D
M. Whitehead, M.D., President
J. M. Lyle, M.D
Will'am Cain, Civil Engineer
W. G. Summons, Chemist
J. W. Jones. M.D., President
John McDonald
S. H. Lyle, M.D
W. G. Simmons, Chemist
Arthur Winslow. Civil Engineer
R. H. Lewis. M.D
Thomas F. Wood, Secretary
William D. Hilliard, M.D
Arthur Winslow, Civil Engineer
W. G. Simmons. Chemist , —
J. H. Tucker, M.D
R. H. Lewis, M.D.. Secretary
H. T. Bahnson, M.D.. President
Authur Wins'ow, Civil Engineer
W. G. Simmons. Chemist
J. H. Tucker, M.D
J. L. Ludlow, Civil Engineer
J. H. Tucker, M.D
F. P. Venable, Ph.D.. Chemist
J. L. Ludlow, Civil Engineer
J. A. Hodges, M.D
J. M. Baker, M.D
J. H. Tucker, M.D
F. P. Venable, Ph.D., Chemist
J. L. Ludlow, Civil Engineer
Thomas F. Wood, M.D., Seci-etary*
George G. Thomas, M.D., President
S. Westray Battle, M.D
W. H. Harrell, M.D
John Whitehead, M.D
W. H. G. Lucas
F. P. Venable, Ph.D., Chemist
John C. Chase, Civil Engineer
R. H. Lewis, Secretary
W. P. Beall, M.D
W. J. Lumsden, M.D
John Whitehead, M.D
W. H. Harrell, M.D — __
W. P. Beall, M.D
R. H. Lewis, M.D., Secretary
F. P. Venable, Ph.D., Chemist
John C. Chase. Civil Engineer
Charles J. O'Hagan, M.D
John D. Spicer, M.D
J. L. Nicholson, M.D
R. H. Lewis, M.D., Secretary
A. W. Shaffer, Civil Engineer
Charles O'Hagan. M.D
J. L. Nicholson, M.D
Albert Anderson, M.D
R. H. Lewis, M.D., Secretary
A. W. Shaffer, Civil Engineer
Address
Rocky Point
Wilmington
Charlotte
New Bern
Raleigh
Warrenton
Rocky Point
Wilmington
Greenville .
Warrenton
Salisbury
Lexinsrton
Franklin
Chapel Hil*
Charlotte
Lexington
Salisbury
FrankMn
Charlotte ;_
Wake Forest
Wake Forest
Washington
Franklin .
Wake Forest
Raleigh
Raleigh
Wilmington ,
Asheville
Raleigh
Wake Forest
Henderson
Raleigh
Winston-Salem
Raleigh '_
Wake Forest
Henderson
Winston
Hendereson
Chapel Hill
Winston
Fayetteville :
Tarboro
Henderson
Chapei Hill
Winston
Wilmington
Wilmington
Asheville
Williamston
Salisbury
White Hall
Chapel Hill
Wilmington
Raleigh
Greensboro
Elizabeth C!ty__
Salisbury
Wi'liamston
Greensboro
Raleigh
Chapel Hill
Wilmington
Raleigh
Goldsboro
Richlands
Raleigh
Raleigh .
Greenville
Richlands
Wilson
Raleigh
Raleigh
Appointed by
State Society
State Society
State Society
State Society
State Society
State Society
State Society
State Soc'ety
State Society
State Soc'ety
State Soc'ety
State Society
Gov. Z. B. Vance
Gov. Z. B. Vance
Gov. Z. B. Vance
State Society .
State Society
Gov. T. J. Jarvis
Gov. T. J. Jarvis
Gov. T. J. Jarvis
State Society
State Society
Gov. T. Jarvis
Gov. T. Jarvis-^
Gov. T. Jarvis
State Board of Health
State Soc-iety
State Society
Goov. A. M. Scales
Goov. A. M. Scales
Goov. A. M. Scales
State Society
State Society
Goov. A. M. Scales
Goov. A. M. Scales__
Goov. A. M. Scales
Goov. A. M. Scales
Gov. D. G. Fowle
Gov. D. G. Fowle
Gov. D. G. Fowle
State Society
State Society
Gov. T. M. Holt
Gov. T. M. Holt
Gov. T. M. Holt
State Society
State Board of Health
State Society
State Society
State Board of Health
Gov. Elias Carr
Gov. Elias Carr
Gov. Elias Carr
Gov. Elias Carr
Gov. Elias Carr
Gov. Elias Carr
State Society
State Society
Gov. Elias Carr
Gov. Elias Carr
Gov. Elias Carr
Gov. Elias Carr
Gov. D. L. Russell-
Gov. D. L. Russell__.
Gov. D. L. Russell___
Gov. D. L. Russell
Gov. D. L. Russell- —
Gov. D- L. Russell
Gov. D. L. RusselL__
Gov. D. L. Russell
Gov. D. L. Russell ___
Gov. D. L. Russell
Gov. D. L. Russell
Term
1877 to
1877 to
1877 to
1877 to
1877 to
1877 to
1878 to
1878 to
1878 to
1878 to
1878 to
1878 to
1878 to
1878 to
1878 to
1881 to
1881 to
1881 to
1881 to
1881 to
1883 to
1883 to
1883 to
1883 to
1883 to
1884 to
1885 to
188.5 to
1885 to
1885 to
1885 to
1SS7 to
1887 to
1887 to
1887 to
1887 to
1888 to
1888 to
1888 to
1889 to
1889 to
1889 to
1891 to
1891 to
1891 to
1891 to
1892 to
1891 to
1892 to
1893 to
1°'>'^ to
1893 to
1893 to
1893 to
1894 to
1895 to
1895 to
1895 to
1895 to
1895 to
1895 to
1895 to
1897 to
1897 to
1897 to
1897 to
1897 to
1899 to
1899 to
1899 to
1899 to
1899 to
1899 to
*Died in 1892. leaving a five-year unexpired term, wh'ch was filled by the Board.
XIV
NORTH CAROLINA MEDICAL SOCIETY
ROSTER OF MEMBERS— Continued
Name
George G. Thomas, M.D., President.
S. Westray Battle, M.D
H. W. Lewis, M.D
H. H. Dodson, M.D.
R. H. Lewis, M.D., Secretary
W. P. Ivey. M.D
George G. Thomas, M.D., President-
Francis Duffy, M.D
J. L. Ludlow, Civil Engineer
S. Westray Battle, M.D
H. W. Lewis, M.D
W. H. Whitehead, M.D
J. L. Nicholson, M.D
J. L. Ludlow, Civil Engineer
J. Howell Way, M.D
W. O. Spencer, M.D
George G. Thomas, M.D., President.
Thomas E. Anderson, M.D
R. H. Lewis, M.D
E. C. Register, M.D
David T. Tayloe, M.D
James A. Burroughs, M.D.*
J. E. Ashcraft, M.D
J. L. Ludlow, Civil Engineer
J. Howell Way, M.D., President
W. O. Spencer, M.D
Thomas E. Anderson, M.D
Charles O'H. Laughinghouse, M.D.-
R. H. Lewis, M.D
Edw. J. Wood, M.D
A. A. Kent, M.D
Cyrus Thompson, M.D
Fletcher R. Harris, M.D
J. L. Ludlow, Civil Engineer
J. Howell Way, M.D., President
E. C. Register, M.D.*
Thomas E. Anderson, M.D
Charles O'H. Laughinghouse, M.D._
Cyrus Thompson, M.D
F etcher R. Harris, M.D
R. H. Lewis, M.D
E. J. Tucker. D.D.S
A. J. Crowell
Address
Wilmington
Asheville
Jackson
MIton
Raleigh
Lenoir
Wilmington
New Bern
Winston
Asheville
Jr.ckscn
Rocky Mount
R'chlands
Winston
Waynesville ^
Winston
Wilmington
States ville
Raleigh
Charlotte
Washington
Asheville
Monroe
Winston-Salem. -
Waynesville
Winston-Salem. _
States viTe
Greenville
Raleigh
Wilmington
Lenoir
.Jacksonville .
Henderson
Winston-Salem..
Waynseville..
Charlotte
Statesville
Greenville
Jacksonvil'e
Henderson
Raleigh
Roxboro
Charlotte
Appointed by
State Society
State Society
State Society
State Society
Gov. C. B. Aycocok..
Gov. C. B. Aycocok
Gov. C. B. Aycocok
Gov. C. B. Aycocok
Gov. C. B. Aycocok
State Society
State Society
State Society
State Society
Gov. C. B. Aycocok
Gov. R. B. Glenn
Gov. R. B. Glenn
State Society
State Society
Gov. R. B. Glenn
Gov. R. B. Glenn
State Society
State Society
State Board of Healtl.
Gov. W. W. Kitch-n.
Gov. W. W. Kitchin.
Gov. W. W. Kitchin
State Society
State Society
Gov. Locke Craig
Gov. Locke Craig
State Society
State Society
State Board of Healt
Gov. Locke Craig
Gov. T. W. Bickett_-
Gov. T. W. Bickett—
State Society
State Society
State Society
State Society
Gov. T. W. Bickett_.
Gov. T. W. Bickett_
Gov. T. W. Bickett._,
Term
1899 to 1901
1899 to 1901
1899 to 1901
1899 to 1901
1901 to 1907
1901 to 1907
1901 to 1905
1901 to 1905
1901 to 1905
1901 to 1907
1901 to 1907
1901 to 1905
1901 to 1905
1903 to 1909
1905 to 1911
1905 to 1911
1905 to 1911
1905 to 1911
1907 to 1913
1907 to 1913
1907 to 1913
1907 to 1909
1909 to 1913
1909 to 1915
1911 to 1917
1911 to 1917
1911 to 1917
1911 to 1917
1913 to 1919
1913 to 1919
1913 to 1915
1913 to 1919
1913 to 1919
1915 to 1921
1917 to 1923
1917 to 1923
1917 to 1923
1917 to 1923
1919 to 1925
1919 to 1925
1919 to 1925
1919 to 1925
1919 to 1923
♦Died leaving unexpired term.
tResigned to become member of General Assembly.
STATUS OF MEMBERSHIP
XV
STATUS OF SOCIETY
MEMBERSHIP BY
COUNTIES FOR
YEARS 1907-1920
Counties
1 1 1
190711908 1909|1910|1911
1 1 1 1
1912
1913
1914
1 1 1
1915 1916|1917| 1918
i
191911920
Alamance
7
17
15
14
12
11
11
13
9
10
12
10
15
1
27
A l«-u-r,T»,4oH n
Alleghany
Anson
Ashe
Avery
Beaufort
_l
2
2
1
3
1 1
1
1
6
8
7
1
3
2
1
1
11
15
8
7
I
8
7
9
9
7
6
4
15
1 151 11
111 16
15
14
14
14
14
10
111 10
14
Bertie
4
41 4
51 2
2
2
3
3
3
3
5
5
10
Bladen
4
4
3
3
4
3
2
1 4
2
4
2
5
5
7
4
7
5
6
9
8
2
9
2
8
Brunswick ."
Buncombe
2
47
48
54
58
63
64
69
68
70
71
74
76
81
83
Burke
10
f
1 10
13
12
11
13
15
17
17
16
17
6
11
Cabarrus
13
17
16
18
21
21
19
22
23
25
20
22
19
20
Caldwell _ J
10
12
12
13
12
10
12
12
11
7
9
13
12
10
Carteret
9
10
7
7
6
7
6
7
7
9
7
4
7
9
Caswell
3
3
2
1
1
1
1
1
1
1
1
1
3
2
10
q
I''
12
15
13
18
5
18
Chatham
6
1
2
2
6
14
15
12
11
11
11
7
10
Cherokee
9
6
7
7
9
5
8
8
7
9
10
7
9
4
11
3
10
6
6
10
8
Clay c
Cleveland
14
14
13
13
14
15
15
16
13
13
16
16
17
19
Columbus
9
8
8
8
10
12
12
14
9
11
7
1
6
10
Craven
10
14
14
14
12
14
18
15
11
8
11
7
7
6
Cumberland
12
12
17
20
20
22
23
22
24
19
17
16
15
20
Currituck
6
3
3
6
4
4
4
6
7
6
6
1
5
5
Dare d
Dav"-dson
12
12
12
13
13
15
13
17
13
9
20
20
19
18
6
8
6
8
6
10
6
10
5
9
6
8
6
7
5
10
4
9
4
9
4
Duplin
9
7
4
10
Durham-Orange
15
18
24
26
28
31
32
38
40
41
44
35
33
45
Edgecombe _ _
8
8
10
10
11
11
11
13
13
13
10
10
7
15
Forsyth
21
26
30
25
29
31
32
37
39
42
45
37
37
57
Franklin
10
10
9
11
11
11
10
10
12
11
10
11
11
12
Gaston _ _ _
22
25
25
27
29
29
30
27
26
25
27
27
26
35
Gates
4
4
'
1
Granvi'le _,
8
11
12
12
8
13
12
14
11
16
16
14
14
15
Greene _
5
5
• 6
6
6
5
5
5
5
6
5
2
5
6
Gu'lford
54
10
62
10
64
7
65
6
56
2
58
2
59
11
62
11
71
7
66
15
68
8
67
1
72
7
77
Halifax
28
Harnett
16
18
19
15
14
17
17
16
17
15
17
15
14
16
Haywood
10
11
15
13
10
11
13
15
11
11
11
9
9
11
Henderson-Polk
n
15
14
14
17
17
11
14
14
15
15
11
13
15
Hertford _ .
8
9
8
6
2
S
10
4
1
5
10
10
10
Hoke- _
10
11
1
10
2
10
Hyde _
5
8
6
6
6
7
7
1
Iredell-Alexander__
18
18
18
17
12
9
9
14
16
9
20
11
11
21
Jackson _
2
11
2
15
2
18
3
19
5
21
2
19
5
22
2
16
5
24
5
Johnston
13
15
19
18
22
Jones _ _ _
Lee
7
9
8
12
7
14
8
15
8
16
6
15
8
17
8
Lenoir '
12
13
9
12
6
8
22
Lincoln
8
8
10
10
10
11
12
13
14
11
9
11
15
16
Macon-Clay _ _
3
11
9
4
11
9
5
12
13
4
7
13
4
8
14
5
11
14
5
9
15
4
10
17
6
"l2
6
11
11
fi
Madison
10
12
11
Martin
13
13
16
McDowell
7
8
4
5
6
6
7
7
7
8
7
6
6
37
54
51
57
44
50
63
69
71
74
63
49
97
104
Mitchell
3
4
7
4
5
5
4
2
2
2
1
4
5
Montgomery
6
8
7
9
7
7
8
6
10
9
9
8
6
8
Moore
2
14
10
11
21
21
13
16
15
18
10
15
16
16
Nash
1
22
~'31
19
28
18
33
26
41
27
•30
21
29
26
38
?5
New Hanover
20
21
23
21
21
40
Northampton
9
9
8
11
9
1
12
12
11
10
14
11
13
10
Onslow
4
4
4
6
11
10
12
10
8
9
11
7
9
8
Orange e .
1
■ 31
1
4
1
5
11
41
1
4
1
4
8
5
Pamlico
5
5
5
5
4
41
5
Pasquotank-Camden-
Dare
11
10
10
11
12
12
13
15
15
171 19
16
15
16
Pender
2
2
2
2
1
1
3
12
1
Perquimans _ ._ _.
4
Person
7
8
9
9
10
11
11
8
11
131 12
10
Pitt
11
9
14
10
10
SI
9
5
15
9) 14
5
18
24
Polk f
___-!
XVI
NORTH CAROLINA MEDICAL SOCIETY
STATUS OF SOCIETY MEMBERSHIP BY COUNTIES— (Continued)
Randolph
Richmond
Robeson .
Rockingham
Rowan
Rutherford
Sampson
Scotland
Stanly
Stokes
Surry
Swain , ,
Transylvania
Tyrrell g
Union
Vance
Wake
Warren
Washington-Tyrrell
Watauga
Wayne
Wilkes
Wilson
Yadkin
Yancey
Totals.
I I I I I I I I I I I I I
1907|1908|1909|1910|1911|1912I1913|1914|1915 191611917119181191911920
I I I I I I I I I I I
6
9
9
10
8
9
7
12
14
11
13
11
12
13
11
11
1
12
1
10
10
13
13
14
11
13
12
24
24
20
15
22
23
35
. 24
16
22
16
8
31
35
5
5
1
16
16
16
18
19
17
10
4
15
16
20
27
25
23
24
26
24
23
26
22
25
23
22
24
28
16
17
22
23
24
18
19
20
19
21
14
17
18
?;o
9
11
10
11
11
12
12
14
14
18
15
• 10
11
13
8
11
10
11
9
9
11
12
12
12
13
10
9
10
9
9
8
11
10
11
11
13
14
9
14
11
11
15
5
10
11
9
10
11
7
12
13
12
10
5
5
10
13
15
15
15
13
14
19
21
19
18
23
24
27
28
6
6
4
8
1
6
5
7
2
1
3
4
5
5
6
7
6
7
1
14
14
14
14
15
16
17
16
16
12
13
15
14
16
6
8
9
12
11
11
11
10
11
13
10
4
5
11
42
44
49
53
56
54
41
53
57
62
70
56
81
68
2
4
5
5
5
8
7
7
6
3
8
13
-I 4|
11
17
6
13
28
10
29
2
865| 979|1012| 997| 996|1036|1133|1220|1221|1228|1271|1087|1306|1497
a See Iredell-Alexander ; b see Pasquotank-Camden-Dare ; c see Macon-Clay ; d see Pasquo-
tank-Camden-Dare ; e see Durham-Orange ; f see Henderson-Po"k ; g see Washington-Tyrrell.
HONORARY FELLOWS XVII
HONORARY FELLOWS, MEDICAL SOCIETY OF THE STATE OF
NORTH CAROLINA
Adams, M. R Statesville
Alexander, Annie L Charlotte
*Alston, B. P , Epsom
Andereson, Albert Raleigh
Anderson, Thos. Eli Statesville
*Archey, L. M._ Concord
Asbury, F. E Ashboro
Attamore, Geo. S Stonewall
*Bahnson, H. T Winston-Salem
Baker, J. M - Tarboro
*Barrier, P. A Mount Pleasant
Battle, J. T. J Greensboro
Battle, Kemp P Raleigh
Battle, S. W ■_ - !___. Asheville
Beall, Wm. P _ Greensboro
^Bellamy, W. J. H Wilmington
Boddie, N. P Durham
Bolton, Mahlon Rich Square
*Booth, Samuel D ^__i Oxford
*Bulluck, D. Wm Wilmington
Caldwell, D. G - _- Concord
Cheatham, Archibald Durham
Clark, G. L , Clarkton
Council, J. B ..-.Salisbury
*Croom, J. D Maxton
Dalton^ Davie N _ Winston-Salem
DeArmon, J, McC Charlotte
Denny, Wm. W Pink Hill
Dillard, Richard Jr Edenton
Dodson, H. H Greensboro
*Duffy, Charles New Bern
*Duffy, Francis New Bern
Edgerton, Jas. L Hendersonville
Edwards, G. G Hookerton
Faison, L W Charlotte
Faison, Wm. W Goldsboro
Fletcher, M. H Asheville
Fox, M. F Guilford Colloge
Freeman, R, A.__- Burlington
Galloway, W. C Wilmington
Gibbon, Robert L Charlotte
Goodwin, A. W Raleigh
*Graham, Joseph Charlotte
Graham, Wm. A Charlotte
Griffin, J. A Clayton
^Deceased
XVUl NORTH CAROLINA MEDICAL SOCIETY
*Hall, Wright Wilmington
Hargrove, R. H Robersonville
Harris, F. R - Henderson
Harris, I. A Alexander, R-2
Haywood, F. J Raleigh
Haywood, Hubert Raleigh
Hicks, Wm. N Durham
Hill, L. H Germanton
*Hudson, Wm. L Dunn
Hughes, F. W ^^ , New Bern
Hunter, L. W Charlotte
Irwin, J. R Charlotte
Jewett, R. D Wilmington
Johnson, N. M Durham
Jordan, T, M Raleigh
Knight, J. B. H Williamston
Knox, A. W Raleigh
Leggett, Kenelm Hobgood
Lewis, H. W._- Jackson
Lewis, R. H Raleigh
Long, Benj. L Hamilton
*Long, Geo. W , Graham
Long, J. W '- Greensboro
Love, W. J Wilmington
McDonald, A. D Wilmington
*McKay, A. M Summerville
*McKay, John A._ Buies Creek
*McKee, James , Raleigh
McMillan, Benj. F Red Springs
McMillan, J. D , . Edenton
McMillan, J. L Red Springs
McMillan, W. D ^Wilmington
McNeill, J. Wm Fayetteville
*McNeill, Wm. M Buies Creek
Meisenheimer, C. A Charlotte
Meisenheimer, Thos. F Morven
*Miller, J. F Goldsboro
Monroe, W. A Sanford
Moore, C. E Wilson
Moore, Edwin G ^ Elm City
Munroe, J. P Charlotte
*Nicholson, J. L Richland
Nicholson, Sam T Washington
Nobles, Jos. E Greenville
Noble, R. J Selma
*Pate, Wm. T Gibson
Pemberton, Wm. D Concord
Perry, M. P Macon
Pharr, T. F Concord
Pharr, Wm. W Charlotte
HONORARY FELLOWS XIX
Picot, L. J Littleton
*Prinee, D. M Laurinburg
Purfoy, G. W Asheville
*Register, E. C Charlotte
*Ritter, F. W Moyock
Royster, W. I Raleigh
Schomvald, J. T Wilmington
Shaffner, J. F. Jr Winston-Salem
Sikes, G. T Grissom
Smith, R. A Goldsboro
Speight, R. H., Sr Whitakers
Stamps, Thos. Lumber Bidge
*Stevens, J. A Clinton
Summerell, E. M China Grove
Tayloe, D. T Washington
Taylor, L M Morganton
Thomas, G. G Wilmington
Trantham, H. T . Salisbury
Tull, Henry Kinston
Van Pool, C. M Salisbury
Ward, W. H Plymouth
Way, J. Howell Waynesville
Weaver, H. B Asheville
Whitaker, R. A Kinston
White, J. W Wilkesboro.
Whitehead, John Salisbury
*Whitehead, W. H Rocky Mount
Whitfield, Wm. C Grifton
Whittington, W. P Asheville
Williams, J. H Asheville
Wilson, A. R Greensboro
*Young, R. S Concord
HONORARY MEMBERS, MEDICAL SOCIETY OF THE STATE OF
NORTH CAROLINA
'L. McL. Tiffany 1 Baltimore, Md.
W. W. Keen Philadelphia, Pa.
J. Allison Hodges Richmond, Va.
=R. L. Payne , Norfolk, Va.
J. N. McCormack Bowling Green, Ky.
R. L. Payne, Jr Norfolk, Va.
J. L. Ludlow, C.E Winston-Salem
Paul V. Anderson Richmond, Va.
Stuart McGuire Richmond, Va.
William J. Mayo Rochester, Minn.
William Seaman Bainbridge New York, N. Y;
William Sharp__ New York, N. Y.
XX NORTH CAROLINA MEDICAL SOCIETY
OFFICERS, 1919-1920
President Dr. C, V. Reynolds, Asheville
First Vice-President Dr. H. D. Walker, Elizabeth City
Second Vice-President Dr. F. Stanley Whitaker, Kinston
Third Vice-President Dr. Thos. I. Fox, Franklinville
Secretary-Treasurer Dr. Benj. K. Hays, Oxford
OFFICERS, 1920-1921
President Dr. Thos. E. Anderson, Statesville
First Vice-President Dr. C. S. Lawrence, Winston-Salem
Second Vice-President Dr. W. H. Ward, Plymouth
Third Vice-President Dr. Jno. M. Manning, Durham
COUNCILORS, 1919-1922
First District— Dr. B. F. Halsey Roper
Second District— Dr. K. P. B. Bonner Morehead City
Third District— Dr. J. W. Tankersly Wilmington
Fourth District — Dr. E. T. Dickinson Wilson
Fifth District— Dr. A. McN. Blair Southern Pines
Sixth District— Dr. W. C. Horton Raleigh
Seventh District — Dr. L. A. Crowell Lincolnton
Eighth District— Dr. J. K. Pepper Winston-Salem
Ninth District— Dr. M. R. Adams Statesville
Tenth District — Dr. Eug. B. Glenn Asheville
CHAIRMEN OF SECTIONS
1921 Session
Public Health and Education Dr. Chas. P. Mangum, Kinston, N. C.
Surgei-y Dr. J. T. Burrus, High Point, N. C.
Eye, Ear^ Nose and Throat Dr. H. H. Briggs, Asheville, N. C.
Gynecology and Obstetrics Dr. Moir S. Martin, Mount Airy, N. C.
Pediatrics Dr. Yates Faison, Charlotte, N. C.
Practice of Medicine Dr. F. M. Hanes, Winston-Salem, N. C.
Chemistry, Materia Medica and Therapeutics —
Dr. Ernest S. Bullock, Wilmington, N. C.
Anatomy, Physiology, Pathology and Bacteriology —
Dr. Paul H. Ringer, Asheville, N. C.
Chairman Committee on Obituaries Dr. E. G. Moore, Elm City, N. C.
PROGRAM
GENERAL SESSIONS
Tuesday, April 20, 9 a. m.
OPENING EXERCISES— FIRST FLOOR, MASONIC TEMPLE
Call to Order:
Dr. J. B. Witherspoon, Chairman, Committee on Arrangements, Char-
lotte, N. C.
Invocation:
Dr. Bunyan McLeod, Westminster Presbyterian Church, Charlotte, N. C.
Welcome to the City of Charlotte:
Hon. F. R. McNinch, Mayor, Charlotte, N. C.
Welcome to Mecklenburg County:
Hon. Cameron Morrison, Charlotte, N. C.
Welcome from Mecklenburg County Medical Society:
Dr. C. M. Strong, President, Charlotte, N. C.
Response:
Dr. Thompson Fraser, Asheville, N. C.
President's Address:
Dr. C. V. Reynolds, Asheville, N. C.
Report of Committee on Arrangements.
Announcements.
Continue in this room with the Section on Public Health and Education,
Tuesday, April 20, 2:30 p. m.
THIRD FLOOR, MASONIC TEMPLE
Meeting of House of Delegates.
Subsequent meetings at same place; time fixed by House of Delegates.
Tuesday, April 20, 8 p. m.
FIRST FLOOR, MASONIC TEMPLE
Pneumoperitoneum as a New Roentgen Diagnostic Procedure (with
lantern slides) — Dr. Fred M. Hodges, Richmond, Va.
Report of Obituary Committee — Dr. Arch Cheatham, Chairman, Dur-
ham, N. C; Dr. E. G. Moore, Elm City, N. C; Dr. F. R. Harris, Henderson,
N. C; Dr. N. D. Bitting, Durham, N. C; Dr. B. O. Edwards, Asheville, N. C.
Wednesday, April 21, 11:15 a. m.
FIRST FLOOR, MASONIC TEMPLE
Nominations for seven vacancies on the Board of Medical Examiners.
Wednesday, April 21, 12 m.
FIRST FLOOR, MASONIC TEMPLE
Conjoint session of the Medical Society of the State of North Carolina
and the Noiiih Carolina State Board of Health.
NORTH CAROLINA MEDICAL SOCIETY
MEMBERS OF THE STATE BOARD OF HEALTH
President, Dr. J. Howell Way, Waynesville, N. C.
Dr. Richard H. Lewis, Raleigh, N. C.
Col. J. L. Ludilow, C.E., Winston-Salem, N. C.
Dr. Thomas E. Anderson, Statesville, N. C.
Dr. Chas. O'H. Laughinghouse, Greenville, N. C.
Dr. F. R. Harris, Henderson, N. C.
Dr. Cyrus Thompson, Jacksonville, N. C.
Dr. A. J. Crowell, Charlotte, N. C.
Dr. E. J. Tucker, Roxboro, N. C.
EXECUTIVE STAFF OF THE STATE BOARD OF HEALTH
Secretary-Treasurer — Dr. W. S. Rankin, Raleigh^ N. C.
Director Public Health Education — Mr. R. B. Wilson, Raleigh, N. C.
Director of Bureau of Tuberculosis — Dr. L. B. McBrayer, Sanatorium, N. C.
Director of Bureau of Medical Inspection of Schools — Dr. G. M. Cooper,
Raleigh, N. C.
Director of Bureau of Public Health Nursing and Infant Hygiene — Miss Rose
M. Ehrenfeld, R. N., Raleigh, N. C.
Deputy State Registrar and Epidemiologist — Dr. F. M. Register, Raleigh,
N. C.
Director of Bureau of County Health Work— Dr. K. E. Miller, R,aleigh, N. C.
Director of Bureau of Inspection and Sanitary Engineering — Mr. H. E.
Miller, Raleigh, N. C.
Director of Bureau of Venereal Diseases — Dr. Millard Knowlton, Raleigh,
N. C.
Director of State Laboratory of Hygiene — Dr. C. A. Shore, Raleigh, N. C.
ORDER OF BUSINESS
Report of work accomplished and recommendations.
Discussions.
New Business.
Adjournment.
Wednesday, April 21, 2:30 p. m.
FIRST FLOOR, MASONIC TEMPLE
Balloting for seven members of the Board of Medicall Examiners of the
State of North Carolina. Vote for seven different names.
Program of the Section on Medicine, as per schedule, will be continued
in this room iis soon as the ballots are taken up.
Wednesday, April 21, 8 p. m.
FIRST FLOOR, MASONIC TEMPLE
New Conceptions Relative to the Treatment of Malignant Diseases and
Some Other Refractory Pathological Conditions (illustrated by lantern
slides) — Dr. Wm. L. Clark, Philadelphia, Pa.
State Medicine — Dr. W. S. Rankin, President of the American Public
Heallth Association, Raleigh, N. C.
PROGRAM
Thursday^ April 22, 11a. m.
FIRST FLOOR. MASONIC TEMPLE
Report of House of Delegates.
Installation of Officers.
Resolutions.
Adjournment.
SECTION MEETINGS '
Tuesday, April 20, 11 a. m.
FIRST FLOOR, MASONIC TEMPLE
Section on Public Health and Education
Dr. C. C. Hudson, Chairman, Charlotte, N. C.
(City Health Officer, Richmond, Va.)
(This section must be finished by the close of the Tuesday afetmoon
session.)
1. Medical Needs of a Modern Community — Dr. A. McR. Crouch, Wilming-
ton, N. C.
2. An Ideal Nursing Organization — Miss G. E. Reynolds, R. N., Charlotte,
N. C.
3. (a) The Importance of a City Tuberculosis Sanatorium; (b) City Abat-
toir and Meat Inspection — Dr. R. L. Carlton, Winston-Salem, N. C.
4. Remedial Conditions in School Children — Dr. Margery J. Lord^ Ashe-
ville, N. C.
5. The State Plan for Securing Medical and Dental Care of School Children
— Dr. Geo. M. Cooper, Raleigh, N. C.
6. Our Tuberculosis Problems — Dr. B. O. Edwards, Asheville, N. C.
7. Some of the Things Necessary to Banish Tuberculosis from Our Com-
monwealth — Dr. Jas. E. Brooks, Blowing Rock, N. C.
8. The Proper Education of Tuberculous Patients While in a Sanatorium —
Dr. Benj. K. Hays, Oxford, N. C. (National Tuberculosis Association,
381 Fourth Ave., N. Y. C.)
9. Symposium' on Venereal Diseases:
(a) Venereail Diseases a Public Problem — Dr. Millard Knowlton, Ral-
eigh, N. C.
(b) The State Venereal Disease Campaign — Dr. Millard Knowlton,
Raleigh, N. C.
(c) Ideal Venereal Disease Clinic — Dr. S. Raymond Thompson^ Char-
lotte, N. C.
(d) The Importance of Laboratory Facilities for Venereal Disease
Clinic— Dr. L. C. Todd, Charlotte, N. C.
(e) Gonorrheal Complications as Related to Infectivity — Dr. A. F.
Toole, Asheville, N. C.
(f) The Diagnosis and Treatment of Syphilis — Dr. C. 0. Abemethy,
Raleigh, N. C.
(g) Central Nervous System Syphilis, Its Incidence and Treatment —
Dr. Joseph A. Elliott, Charlotte, N. C.
(h) The Treatment of Gonorrhea in the Female — Drs. Jas. A. Keiger
and A. B. Greenwood, Raleigh, N. C.
(i) The Importance of Proper Treatment in Acute Gonorrhea — Dr. A.
McR. Crouch, Wilmington.
Discussion opened by Prof. Udo J. Wile, of University of Michigan (by
invitation).
XXVI NORTH CAROLINA MEDICAL SOCIETY
Tuesday, April 20, 2:30 p. m.
Section on Public Health and Education
FIRST FLOOR, MASONIC TEMPLE
(Continuing)
Tuesday, April 20, 2:20 p. m.
THIRD FLOOR, MASONIC TEMPLE
Section on Eye^ Ear, Nose and Throat
Dr. C. W. Banner, Chairman, Greensboro, N. C.
1. Some Deductions from a Series of 200 Tonsilectomies — Dr. T. W. Davis,
Winston-Salem, N. C.
2. Report of 100 Cases of Tonsilectomy Under Local and General Anesthe-
sia — Dr. L. L. Simmons, Greensboro, N. C.
3. Query: What Constitutes Good Tonsil Surgery? — Dr. John W. Mac-
Connelly Davidson, N. C.
4. Title unannounced — Dr. S. Dace McPherson, Durham, N. C.
5. Title unannounced — Dr. J. G. Murphy, Wilmington, N. C.
6. Relation of Public Hea'lth Work to the Business Interest of the Special-
ists of North Carolina — Dr. G. M. Cooper, Raleigh, N. C.
7. Title unannounced — Dr. John Hill Tucker, Charlotte, N. C.
8. The Relative' Value of Transillumination and X-ray in Diagnosing Dis-
eases of the Nasal Accessory Sinuses, w^ith Description of the Au-
thor's Method of Transilluminating the Maxillary Sinus (lantern
slides) — Dr. H, H. Briggs, Asheville, N. C.
Wednesday, April 21, 9 a. m.
THIRD FLOOR, MASONIC TEMPLE
Section on Gynecology and Obstetrics
Dr. J. M. Manning, Chairman, Durham, N. C.
1. Some Phases of Obstetrics — Dr. J. M. Manning, Durham, N. C.
2. Subject unannounced — Dr. Foy Roberson^ Durham, N. G.
3. Cesarean Section — Dr. C. A. Woodard, Wilson, N. C.
4. Subject unannounced — Dr. J. L. Nicholson, Washington, N. C.
No section meetings after 11:15 a. m. today (Wednesday) as nomina-
tions for members of Board of Medical Examiners will be called at this hour.
Wednesday, April 21, 9 a. m.
THIRD FLOOR, MASONIC TEMPLE
Sectiofi on Pediatrics
Dr. J. Buren Sidbury, Chairman, Wilmington, N. C.
1. The Importance of the Early Recognition of Intra and Extra-durai Hem-
orrhage in the New^-Bom — Dr. J. Buren Sidbury, Wilmington, N. C.
SECTION MEETINGS XXVll
2. Focal Hemorrhagic Encephalitis: Report of a Case with Transfusion —
Dr. A. S. Root, Raleigh, N. C.
3. Intubation of the Larynx for Membranous Croup — Dr. L. T. Royster,
Norfolk, Va.
4. Acidosis — Dr. L. W. Elias, Asheville, N. C.
5. Infection of the New-Born — Dr. Yates W. Faison, Charlotte, N. C.
6. Simplified Infant Feeding^ — Dr. Frank Howard Richardson, Brooklyn^
N. Y.
7. A Discussion of the Use of Purgatives in Infants — Dr. D. L. Smith,
Saluda, N. C.
8. Diabetes Mellitis in Childhood— Dr. R. M. Pollitzer, Charleston, S. C.
9. Skin Tests with Foreign Proteins — Dr. Horace M. Baker, Lumberton,
N. C.
No section meetings after 11:15 today (Wednesday), as nominations for
members of Board of Medical Examiners will be called at this hour.
Wednesday, April 21, 9 a. m.
FIRST FLOOR, MASONIC TEMPLE
Section on Practice of Medicine
Dr. Hubert B. Haywood, Jr., Chairman, Raleigh, N. C.
(This section will adjourn promptly at 11:15 a. m. for the nomination of
seven members of the Board of Medical Examiners. It will reconvene in
the same room at 2:40 p. m. immediately after the ballots are taken up.
This section must be finished at th/^ Wednesday afternoon session.)
1. Specifics in Medicine — Dr. Frederic M. Hanes, Winston-Salem, N. C.
2. A Study of Different Types of Bright's Disease: The Importance of
Their Early Recognition— Dr. Wm. deB, MacNider, Chapel Hill, N. C.
3. Pathologic and Lantern Demonstration of the Influenza and Influenza-
Pneumonia Lung — Dr. Jas. B. Bullitt, Chapel Hill, N. C.
4. X-ray Findings in the Lung Following Influenza, Tuberculous and Oth-
erwise — Dr. Robert P. Noble, Raleigh, N. C.
5. Hyperthyroidism and Tuberculosis: Studies on the Use of the Goetsch
Test— Dr. R. A. McBrayer, Sanatorium, N. C.
6. Essential Hypertension — Dr. R. F. Leinbach, Charlotte, N. C.
7. Syphilis vs. Rheumatism and Neurasthenia, with Report of Illustrative
Cases — Dr. J. Allison Hodges, Richmond, Va.
8. Mechanism of Convulsive Movements of the Face and the Manner of
Their Removal — Dr. Tom A. Williams, Washington, D. C.
9. Anemia: Report of a Case Treated by Transfusions— Dr. K. C. Moore,
Wilson, N. C.
10. Arterial Tension and Its Clinical Manifestations— Dr. Chas. H; Pette,
Warrenton, N. C.
11. The Significance of Abnormal Blood Pressure — Dr. J. T. J. Battle,
Greensboro, N. C.
XXVIU NORTH CAROLINA MEDICAL SOCIETY
12. Some Facts, Old and New, Concerning the Pulse and Heart — Dr. Hubert
B. Haywood. Raleigh, N, C.
13. Toxic Arthralgia, with the Teeth, Tonsils and Stomach as Etiologic
Factors — Dr. O. Edwin Finch, Apex, N. C.
14. Symptomatology of Typhoid Fever — Dr, P. E. Hardee, Stem, N. C.
15. Eventration of the Diaphragm — Dr. Wm. Allan, Charlotte, N. C.
16. Report of a Headache Cured — ^Dr. John H. Tucker, Charlotte, N, C.
17. Syringomyelia, with Report of a Typical Case — Drs. J. P. Munroe and
A. A. Barron, Charlotte, N. C.
Thursday^ April 22, 9 a. m.
FIRST FLOOR, MASONIC TEMPLE
Section on Chemistry^ Materia Medica and Therapeutia
Dr. Chas. S. Mangum, Chairman, Chapel Hill, N, C.
1. Food Values from the Standpoint of the Vitamine Content — Prof. W. A.
Withers Department of Chemistry, North Carolina State College,
Raleigh,' N. C.
2. The Problem of Food Values — Dr. W. P. Horton. North Wilkesboro, N. C.
3. Different Forms of Food Adulteration — ^Mr. W. M. Allen, Food and Oil
Chemist, State Department of Agriculture, Raleigh, N. C.
4. The Chemistry of the Blood in Nephritis — Dr. W. M. Copridge, Durham,
N. C.
5. Treatment of Amoebic Infections — Dr. Wm. Allan, Charlotte, N. C.
6. The Modem Therapeutic Value of Digitalis — 'Dr. Jos. A. Speed, Durham,
N. C.
7. X-ray and Radium Treatment of Skin Affections — Dr. W. D. James,
Hamlet, N. C.
Section on xinatomy. Physiology, Pathology and Bacteriology
Dr. H. P. Barrett, Chairman, Charlotte, N. C.
Illness prevented Dr. Barrett from taking care of the program for his
section.
section meetings xxix
Tuesday^ April 20, 11 a. m.
THIRD FLOOR, MASONIC TEMPLE
Section on Surgery
Dr. E. B. Glenn, Chairman, Asheville, N. C.
(This section must be finished by the close of the Tuesday afternoon
session),
1. Acute Pancreatis, Suggesting Acute Intestinal Obstruction — Dr. E. B.
Glenn, Asheville, N. C.
2. Saving Suppurating Wounds — ^Dr. H. A. Royster, Raleigh, N. C.
3. Goiter: Observations Drawn from 216 Cases (lantern slides) — Dr. Ad-
dison G.. Bemizer, Charlotte, N. C.
4. Imbrication Operation for Inguinal Hernia; 200 Cases Operated; Steps
in Operation (lantern slides) — Dr. J. T. Burrus, High Point, N. C.
5. Some Difficulties in Gall-Bladder Surgery — Dr. J. W. Tankersley, Greens-
boro, N. C.
6. Prostate Toxemia — Dr. Albert D. Parrott, Kinston, N. C.
7. Management of Carcinoma of the Stomach — Dr. T. M. West, Fayette-
ville, N. C.
8. The Treatment of Infected Bone Cavities — Drs. D. W. and Ernest Bul-
lock, Wilmington, N. C.
9. Closure of the Abdominal Wall — Dr. Henry F. Long, Statesville, N. C.
10. Hypertrophic Stenosis of the Pylorus — Dr. E. T. Dickinson, Wilson,
N. C.
11. The End Results of 100 Cases of Cancer of Uterus — Dr. J. A. Williams,
Greensboro, N. C.
12. Subphrenic Abscess — Dr. G. W. Pressley, Charlotte, N. C.
13. Ascariasis as a Surgical Complication — Dr. Henry Norris, Rutherford-
ton, N. C.
14. The Surgeon and Roentgenology (lantern slides) — Dr. Robert H. Laf-
ferty, Charlotte, N. C.
15. A Troublesome Complication of Gonorrhea, Its Treatment — Dr. Hamil-
ton W. McKay, Charlotte, N. C.
16. Treatment of Skull Injuries by the Ordinary Surgeon— Dr. C. M. Strong,
Charlotte, N. C.
17. Flat Feet— Dr. Alonzo Myers, Charlotte, N. C.
18. Drainage — Dr. W. O. Spencer, Winston-Salem, N. C.
Thesday, April 20, 2:30 p. m.
THIRD FLOOR, MASONIC TEMPLE
Section on Surgery
(Continuing)
FOREWORD
At the last session of the Medical Society of the State of North Carolina
at Charlotte, April 20-22, it was understood that Dr. Hays would return
to the State and take up his work here, including the Secretaryship of this
Society, within the two weeks following the meeting. Instead, however,
Dr. Hays took up work with the United States Public Health Service and
has not as yet returned to the State. Therefore, it became my duty to
continue the work as Acting Secretary-Treasurer and I am responsible for
this volume of the Transactions. The diflficultics in getting out this volume
have been many and we crave your indulgence for any errors or omissions.
Respectfully yours,
L. B. McBrayer,
Acting Secretary-Treasurer.
TRANSACTIONS
of the
Sixty-Seventh Annual Session of the
Medical Society of the State of
North Carolina
OPENING EXERCISES
Tuesday Morning, April 20, 1920..
Meeting called to order by Dr. J. B. Witherspoon, Chairman of Com-
mittee of Arrangements, Charlotte, N. C. On the platform were seated
all the Ex-Presidents and Guests of Honor.
"It is my privilege and pleasure to call together the 67th Annual Meet-
ing of the Medical Society of North Carolina. It is fit and proper that we
should first ha^'e the Divine Blessing "
INVOCATION
Dr. Bunyan McLeod, Westminister Presbyterian Church
Charlotte :
"Almighty God who has phmted the day star in the heavens and scattered
the night, restored unto us this morning thy heavenly light, ail things make
us think of Thee. The radiant sunshine, the rapture of the birds, and above
all the thrill that comes into our souls from far off days. Lift upon us thy
light that we may see light, lighten every doubt and fear, lighten every cross
and care, lighten every path and duty. We pray that Thou wilt bless this
Medical Society and every physician that is identified with same.
We offer thanks for the splendid service they render in ministering at
our bed side, in relieving pain, in restoring back to health and strength those
that have been at the bed-side of death. We would think now of the doc-
trine that will never be forgotten in our minds ; serving, toiling, sayings and
doings in the old country, and better still is impressed our God who is keep-
ing his reward for such men. May every phj'sician here feel that the mem-
ory and gratitude to those to whom they minister is far greater than they
could ever anticipate. We welcome these men and pray that God will give
them great deliberation.
We ask this in the name of Him who came in this world not to be min-
istered unto but to minister. Amen.
WELCOME TO THE CITY OF CHARLOTTE
Hon. F. R. McNinch, Mayor, Charlotte, N. C.
Mr. President and Gentlemen of the N. C. Medical Association :
It's a very sincere pleasure to welcome you on behalf of the people > :
Charlotte to our city. Charlotte regards it as a distinct honor that your
noble profession should have selected this place as the place of your gather-
ing. We arje always glad to have meet with us any splendid body of men
but there is a peculiar pleasure and honor to have meet within our gates
the Medical Profession oi North Carolina.
I NORTH CAROLINA MEDICAL SOCIETY
1 believe I am perfectly sincere when I say that I regard your profession
as the one that has contributed more greatly to the condition of mankind
and to relieving of conditions that tend towards suffering and distress, than
any other secular organization. Applause.
It has been my good fortune to get a closer view of the Medical profes-
sion localU'. It is a pleasure for me to testify to the devotion of the local
physicians, to the cause 'A public good. I know of no class of men who have
devoted themselves more to the community's good than the local physicians.
Applause.
1 recall very vividly the distressing times here during the two epidemics
of Flu, particularly the first. To me it was amazing that human beings
could so devote themselves to the relieving of sufiEering. Night and day
many of them devested themselves in a perfectly beautiful manner to the re-
lieving of suffering in their community. Charlotte shall never cease to be
grateful or cease to acknowledge its gratitude to the Medical Profession.
We remember, of course, the grand work done by our profession during
that great war. Many lives were snatched from the very border land of
the other world by the skill and devotion of your profession.
Your highest endeavor and your greatest zeal and energy is directed to-,
wards efforts that would seem at least, to tend towards making your pro-
fession useful. I refer to preventative medicines. Marvelous things have
been accomplished in the last ten years by your profession. Every time one
has a prevention for contraction of a disease, there is one patient less for
the doctors.
The greatest part of your accomplishment in my judgment has been along
the lines of preventative medicines. We not only appreciate the result, but
we appreciate the motive which would prompt a body of men to set them-
selves about for the discovery and removal of a cause which would take away
from their practice. I believe that the highest mark of your profession, is
not treating the disease, but it is in discovering and telling people in advance
how they may escape that disease. That physician in that community who
best serves his people, he is the most useful citizen in the community, save
the Minister of the Gospel. I believe that the physician ought to, and I know
that ihey do here, believe in the advancement of the community in medi-
cine—in the teaching of the public A. B. and C. of health, in order that
they may avoid the contraction of diseases.
In Charlotte we have taken some interest recently in Public Health work.
I don't desire to reflect anything on the past administration — all of us do
the best we can. Charlotte has made an effort to build up a public health
department, and I believe we now have a very efficient health department.
This is due to your profession, the things it has discovered and imparted to
the public. We are very grateful to you — therefore it is our honor in having
you with us this morning. I may no longer truthfully welcome you to the
largest city in North Carolina — may I not without undue modesty suggest
that the little bit lacking in number is more than made up in quality. It
has been three or four months since the census was taken and we are cer-
tain since that time we have grown more.
We hope your stay here will be pleasant and profitable to you, as we are
perfectly certain it will be both to us.
OPEXIXG EXERCISES i
WELCOME TO MECKLENBURG COUNTY
Hon. Cameron Morrison, Charlotte, N .C.
On behalf of the largest County in North Carolina — Mecklenburg-
rich in historic interest; rich in all material things; progressive in every as-
pect of North Carolina life, I w^elcome you to the County of Mecklenburg.
I hope that you will enjoy your stay in our city and I am sure you could
not come among a people where the Doctor is more loved than in the in-
telligent county of Mecklenburg. A great many of our people love the
Ministers; not quite as they should, but all the people of Mecklenburg
County, Saint and Sinner, love the Doctor. You have more friends than
any other like number of men who live in our commonwealth. You have
more friends than any other like number of men, because you have minis-
tered to more men in trouble and distress than any other like number of men
in North Carolina, and it is with pride and pleasure that I welcome you to
our county and assure you that all we have is at your disposal.
This done, I want you to let me trespass for a moment to congratulate
you upon one of the many opportunities which you have to serve humanity
and North Carolina. It is for your profession to say whether or not the
people of North Carolina should be protected in the future by having all
the knowledge of preventative medicines which this enlightened age carries
through you, thrown around the home-life of the State. In this important
aspect of our future the Physicians of North Carolina are the Statesmen of
North Carolina and there is no greater duty before North Carolina in the
future than to see to it that all the knowledge of preventative medicine
which an enlightened world possesses is thrown around the home life of
the people of this State. This duty is the highest duty of Statesmenship and
■. et it cannot be performed except under your guidance, advice and direc-
tion. Applause.
Of .'ill the fools I come in contact with, and they are numerous, of course,
who aggravate me. it is the ignoramus who wants to tell the Doctors of
North Carolina how to protect health and life in the State. We want the
government in North Carolina, which holds itself absolutely subservient to
the advice and skill and wisdom of your great profession. We must have
the best possible Health Administration in North Carolina and in every
community in North Carolina, and the Doctors must organize and guide
the people to see to it that fewer people are sick and suffer and die in North
Carolina in the future than in the past.
We have the reactionary and ignorant ones to deal with, but under the
influence of your profession North Carolina can be blessed by having thrown
around the life of every man, woman and child in North Carolina all the
knowledge of the preventative medicine which your great profession has
worked out for the happiness and protection of humanit\\ The people of
Mecklenburg County recognize your profession as the greatest servant of
humanity, save the man of God. Nearly every preacher is a man of God.
I nevei saw a Doctor in my life who was not a gentleman. I have seen
some that had some sins alright, you know they are not all sanctified. I
never saw many w^ho were not gentlemen, at least in a practical sense, a
Christian. The influence of the Doctors in North Carolina, is next to that
4 NORTH CAROLINA MEDICAL SOCIETY
of the Ministers, and all, the people of Mecklenburg County and North
Carolina are not unmindful of your courageous lives. I can conceive of a
man in the battle-field with the music cheering him on, standing in the
midst of thousands, with all the world and ages to come looking on, but
when I think of a student of medicine or a Doctor off in the laboratory, in
the sick-room, in the midst of disease and death battling with these myster-
ious germs, every day living in the midst of death and danger, I believe you
are braver than any soldier on the battle field.
We never think of anything killing a doctor. We forget "I am scared of
germs." The doctor goes from one room of germs to another as fast as
his poor tired body can carry him for humanity's sake every day of his life.
I believe that as the world becomes enlightened; as education is spread
among the people, they are appreciative of these great enlightened scientific
men who worked out and discovered the mysteries to protect the human life
from suffering ; these men are becoming appreciative more and more as time
goes on.
We may think of the Imperial German — Wilhelm — the greatest one of
misery and warfare, Napoleon the mighty, Foch the recent hero and mili-
tary savior of i-he world are both appreciated but the day will come when
Pasteur, the silent student, who worked in the mysteries of chemistry has
already saved more human lives than these two men ever destroyed, their
work is ended, but the work of Pasteur will go, on, saving and protecting
life, until God winds it all up.
In the future it will be appreciated more by the masses, because the
masses will become more intelligent. I want to urge ever}- Doctor who
hears me to make himself a leader in his community, an organizer in his
community so that North Carolina and every community in it shall cease
the picaunish policy and disregard to the expenditure of money for the pro-
tection of life and health of the people of North Carolina. We alone can
do this. I congratulate you upon the great opportunity which you have to
render this service to the community. We want an Administration in
North Carolina that recognizes that the protection of health of our people
is the highest type of politics and Statesmanship. I hope if it is ever my
good fortune to be Governor of North Carolina (Applause) that the Doc
tors before me in this State will consider me their servant and their agent,
as well as their instrument — that I may win the proud title in the history
of North Carolina — The Health Governor of North Carolina.
WELCOME FROM MECKLENBURG COUNTY MEDICAL
SOCIETY
Dr. C. M. Strong, Pres., Charlotte, N. C.
Members of the North Carolina Medical Society, Ladies and Gentlemen :
The tide of time with its ebb and flow has brought the medicine men
of North Carolina to our city again. Eleven years ago we had the honor of
having you with us, since then the personnel has changed, many new faces
greet us with the blooming hopefulness of the future and also many of the
old guard are missing, and many here are going down the hill. Hence oc-
casions like this bring mingled feelings of gladness and sorrow, but we are
always to remember that the sweets of life are tinged with the wormwood
OPENING EXERCISES J
and the gall and however perfect the day, though its sunset radiates a beauty
not of earth, is followed by the dark.
All over North Carolina today there is medical darkness on account of
your absence from home while here we are basking in the effulgency of an
"Esculapian Sun." We congratulate ourselves on having you medical men
with us also your clientele at home, they will have a chance to get well, a
rest from ills and pills and doctor's bills, what doctors are made of. Then
you doctors will, for a short time, get away from coughs and moans, aches
and groans and all such things that patients are made of. And again you
have a chance to get off your accumulated jokes and rich and rare are the
jokes of the old doctor. A doctor's jokes always goes for he usually sees into
and hears everything at the drug store or country store and blacksmith shop
or, as they are latterly called garages and smaller the shop the larger the
sign like some doctors I know.
Don't fail to tell how many cases of flu pneumonia you had without a
single death and this does not mean that you will not have a "pleural death."
How many young Americans you have ushered into this Bolshevic world in
one night, ten miles apart. How many appendix and tonsils removed which
were not diseased. What make of a Ford car you are driving, what specialty^
you are going into and city to locate in. Don't forget Charlotte. We have
a few vacancies left and are inventing new specialties every day. Talk at
length of the high cost of living and how you are going to meet it charg-
ing the same old fees. By the way have you ordered your overalls, they are
going up every day and will soon be too high to buy. Order now — perhaps
you can get a pair by the first of October, not up to specifications perhaps
and may be striped instead of blue and you must make a deposit of $25.00
down the balance can be paid monthly through the Morris Plan bank. How
you are going to take a rest every year and never do it because Mrs. Smith
is expecting, and you wear yourself out and soon your meeting days are
over.
From the Sand Dunes of the Atlantic, up to the Fertile Lowland, the
industrial Piedmont and the Land of the Sky you come, like the Moham-
medan to his Mecca's Shrine for inspiration or the Hindu to the Sacred
Ganges to wash his sins away. Where will you find a greater inspiration
than at a meeting of the North Carolina Medical Society or where will you
tmd purer water than the sacred Catawba, brewed as it is in natures
Grand Distillery of the Blue Ridge. However, it has been known to be
contaminated with a little corn. Some of the older members can recall that
at a former meeting of this society it was all corn. If, therefore, you find
a single grain in it now please hand it to the Historian as it is more valuable
than the diamond.
As President of the Mecklenburg County Medical Society, of which we
are justly proud, none better and few equal, we bid you welcome, ask
you to visit our five hospitals overflowing with patients and impatience, our
Mayonett Clinics of which we have a few and thus is the trend of medi-
cine. Our Medical Library full of lore and dust — in fact everything medical
except our patients and only talk to them of the weather, as they have some
medical secrets about us doctors which we do not care to have divulged.
Besides they think a visiting doctor knows more than a local one, a pity
ris often true, and we want to avoid anv focal infections.
b NORTH CAROLINA MEDICAL SOCIETY
As North Carolina doctors we welcome you Fellow North Carolinians
and all others wherever you are from, also especially our Suffragette Allies.
Would here say if there is anything characteristic of North Carolinians
it is their individualism you have to show him, not once like the Missou-
rian, but many times and besides we have no big cities to hog it over us
but many good towns. Therefore our doctors are all city and country
doctors and are on an equality hence our coming together is more like a
big family reunion. And at this great family reunion of Tar Heel Doc-
tors throw off all reserve, sit around old Mother Mecklenburg's Big fire-
place, smoke plug tobacco and cob pipe, expectorate in the fire, tell all the
yarns you want, drink a little of the corn, if you can find it and no Pa-
triotic Tar Heel will drink any other kind, speak out in meeting with
no one to molest or make you afraid. After you have received your in-
spiration and your medical sins are washed away may you leave here invig-
orated in body and mind.
Would conclude with the admonition and blessing of the sweet singer of
Israel of the long ago ; when he touched his harp's strings and sang his first
song and said:
"How blessed and happy is the man
Who walketh not astray
In paths of ungodly men
Nor stands in sinners way
You shall be like a tree
Set by the river's side
Whose leaves and fruit
Shall ever green abide
And all you do shall prosper well.
The wicked are not so
But like chaff" before the wind
Are driven to and fro
And may goodness and mercy all your life
Always follow thee
And in "God's House" forever more
Your dwelling place shall be."
RESPONSE
Dr. Thompson Eraser, Asheville, N. C.
"It is nice to be told that we are welcome, even though we feel that
we are, but it is especially nice to be welcomed to Charlotte. I feel that
our stay here will be profitable to us all. I think these medical meetings
are always a sort of inspiration.
"I think we have an opportunity to absorb some of what we may call the
Charlotte spirit, the spirit which has made Charlotte the Queen City of
the Carolinas. She stands before us as an object lesson, civic pride and 100
percent American. I don't need to tell you that Charlotte leads all Amer-
ica as the Textile Center, as second Auto, center in the South, and is fast
pushing Atlanta for its place. I am told that its Hospital accommodation
has increased one thousand percent in the last 15 years. We know that it
is the spirit and energy of Charlotte physicians that has made its Board
OPENING EXERCISES /
of Health what it is. I think you will agree with me that we have an op-
portunity to profit by what we have seen and to carry back some of these
ideas to our home towns. It is a great pleasure to be with you, and in be-
half of the North Carolina Medical Association, I wish to thank the speak-
ers for the courtesy of inviting us here and for their hospitality during our
stay here."
MEDICAL LEGISLATION
ANNUAL ADDRESS OF THE PRESIDENT
' C. V. Reynolds, M. D., Asheville, N. C.
INTRODUCTION
In appearing before you this morning as President of the Medical Society
of the State of North Carolina, and before reading the message, please let
me say that it is with inestimable appreciation that I serve as your presiding
officer and the honor is deemed the greater in that it is the highest that the
State has to offer.
We trust that you are pleased with the scientific program and just here
allow me to express publicly my personal thanks to Dr. L. B. McBrayer
for his wise council, and persistent effort in our behalf. It is largely due to
him, and the chairman of the various sections, that we have such an inter-
esting program.
In searching for a subject to present to you, I could find nothing of un-
usual interest in my possession, so it occurred to me that an economic prob-
lem of such vast importance to the Medical Profession as "Medical Legis-
lation" would be timely, appropriate and, I trust, interesting.
Problem
Rate Per
Typhoid fever caused 10.113 deaths in 1917 13.4 100,000
Malaria fever caused 2,387 deaths in 1917 3.2 100,000
Diph. Croup caused 12,453 deaths in 1917 16.5 100,000
Pneumonia caused 12,821 deaths in 1917 149.8 100,000
Diarrhea (under 2 yrs.) caused 48,231 deaths in 1917 64.0 100,000
186,005
Tuberculosis caused 110,203 deaths in 1917 146.4 100,000
Cancer caused 61,429 deaths in 1917 81.6 100,000
Infants (under 1 yr.) caused__ 17 1,204 — 20% of deaths under 5 vrs. of age.
342,656 deaths in 1917.
Injuries at birth 3.2 in 1910— but 4.6 in 1917.
Premature births increase 17.5 in 1910 to 21.1 in 1917.
What is the cause? It certainly is food for thought.
There were in hospitals for the insane and blind 55,435 due to syphilis and
gonorrhea.
There were 292,519 deaths from diseases for which gonorrhea and syphilis
were greatly resp>onsible.
6 NORTH CAROLINA MEDICAL SOCIETY
There were 1,068,932 deaths in the registration area in 1917- — one-half of
which are preventable.
Then maj^ 1 ask in the beginning — have we a problem ?
With this situation before us — ^with the recent evidence that 35% of our
prime manhood physically defective, with the general citizen of our country
enthusiastically crying for a general re-adjustment, do you think for one
moment that the real and fundamental secret to the success of human en-
deavor will, or should be, overlooked?
Medicine, as an applied science, has through individual, rather than a
collective effort, made marvelous advances through her various avenues of
research ; this reward of merit through individual attainment should not be
lost.
Then it behooves us for the sake of self preservation, if not for the higher
motive, the preservation of humanity, to have a Strong committee to watch,
plan and outline, for those who are endeavoring to pass Medical Legisla-
tion, that we may guide their efforts in the proper way. Never before did
we need, as we do now, intelligent leadership.
THE DOCTOR
The Doctor — "God bless him" — for the people have never paid him, he
has worked harder, longer, suffered more, endured more, and received less
than any other professional man. But this sacrifice has been made in a field
of curative medicine — useful, but growing less important as preventative
measures develop.
No w^ords of appreciation can begin to give justifiable praise to the
doctor, for his willingness to serve humanity, his forgetfulness of self, and
his duty to his family, when facing the rain, the snow, the hail, the wind and
the heat- — no road too long, no hill too steep, no phobia of contagion too
great to prevent his rendering a service to his fellowman. For remunera-
tion ? — yes — but his altruism is, and, I hope, will ever be unquestioned.
Yet, may I ask, have we not neglected our greatest asset to man in await-
ing his call for aid and then attempting a cure, rather than anticipating hi>
ills and preventing his calls. We advise how to (/et well where we should
advise how to keep well.
We are constantly discussing our problems, making known our mistakes,
as well as our accomplishments; we have forged ahead and have done much,
yet we know and the public knows that with our present method we arc
not by one-half, doing what could be done.
Through various agencies, we can do most effective work in preventing
one-half of the present injuries and illnesses. The trend of the public mind
(let this mind be in the control of the philanthropist, the socialist, the re-
publican, the democrat, the mugwamp, the braying mule or the politi-
cian) is toward some type of socialistic medicine. Our apathy, indifference,
or our somnolence toward the passing of Workman's Compensation laws
has caused us, as well as those whom it was intended to serve, to be led mto
\insound, unprofitable, and poorly administrated medical practices.
OPEXINX, EXERCISES 9
Experience has taught us something and we should awaken, ere it is too
late, and realize that certain fundamental changes are to be made, and that
this is necessarj' to society, before we are embarrassed by having our duties
poorly done by incompetents.
Our already accumulated knowledge, if awakened and put into active
service, can reduce sickness and accident one-half. The philanthropists,
the politicians and the people at large have this interesting knowledge —
made possible for them by us, and given to them by our press. Do you
think for one moment that they are going to sit idly by and see this vast
waste of human life ?
Our individual problems may cause us to sit idly by, forgetful of, or,
with indifference to, the greater problems of the community, the state, or
tjie United States health program and we will suffer the consequences of
the inactive, thoughtless, indifferent citizen, and suffer in consequence of
our inactiveness.
The physician is still an individual, and deals with his patient as an in-
dividual, failing to recognize that community interest must and should be
conserved, even at a loss to the individual for the good of many.
The doctor is not mercenary — neither is he pessimistic — nor would I
call him an optimist. He is schooled and trained to think for the preser-
vation of human life, for the betterment of the physical being, realizing
that health is the foundation of happiness, prosperity, and independence,
and that sickness leads to inefficiency, which produces misery, poverity, de-
gradation, crime and vice.
In colonial days, under pioneer conditions, the first requirements in es-
tablishing a village, it matters not how small, was the erection of a church,
a school house, and the securing of a physician — those were the recognized
essentials for the development and. care of the moral, mental and physical
well being.
From the smal) church, the little red school house and the willing physi-
cian, there has grown the glorious cathedral, the advanced facilities for ed-
ucational purposes in our public and private schocjs, and state universities —
the modern phvsician, fresh from colleges of highest advantages, the exper-
ienced surgeon, clinician and bacteriologist.
Vast and wonderful opportunities are most universally offered, yet col-
lectively we have not prospered and made what we should out of our op-
portunities.
In the war census there was found one-fourth illiterate — an utterly in-
adequate number of skilled mechanics and technicians, and one-third of our
young manhood physically unfit.
Of late we have come to realize many of our short comings and is it not
high time for us to set about to prevent the preventable, to correct the cor-
rectable and to cure the curable?
This is an age of reconstruction, and a readjustment of conditions there
will and must be. This, it seems, is the time, and the tide is growing
stronger day by day. As time and tide wait for no man, it behooves us to
■itep in and guide or mold our future before some well meaning philanthro-
pist guides or molds it for us.
10 NORTH CAROLINA MEDICAL SOCIETY
There are numerous ways and not many definite plans already proposed,
and many more will be forth coming — none of which will please us all.
Then the first step in the solution of such a vital question is to select a
special committee to analyze the various suggestions and pick out the fun-
damental element — this committee working in conjunction with a similar
committee from the American Medical Association, the Public Health As-
sociation, the State Board of Health, and the Southern Medical Associa-
tion, to report back to this Society their conclusions for ratification, the
adopting of which should and I believe would bring about a co-operative
effort to work for a common objective.
INSURANCE
When industries were small and the employer did his daily work with
the employee, and w^as the guiding brain, there was a friendly bond be-
tween the two — strife, jealousy and the feeling of the general in-equality i^f
it all was forgotten through this relationship.
As industry has grown, machinery has become the guiding brain of the
former employer, and the personal equation has disappeared. The employee
began to realize that he was an integral part of the industrial machinery,
and that to the injured or those suffering from illness, the employer should
make reparation just as he did in any damage done to the mechanical de-
vices.
The employer removed from this personal equation did not so consider it.
Common la\\- was appealed to by the employee— more justice was not re-
ceived, so in recent years the barriers protecting the employer were broken
down, when the European conception was adopted — replacing the common
law system by a law, based "not on fault, but on the fact of injury resulting
from accident in the course of employment."
The method adopted was insurance by many for the benefit of the in-
jured.
There are various forms of insurance adopted; the lodge insurance, fra-
ternal insurance, social insurance, Vol. Compulsary Accident and Sickness
Insurance, Mutual Insurance, State Insurance, Workman's Compensation
laws, etc., all of which have their advocates and their bitter opponents.
This kind of self perservation on the part of the employer and employee is
taking on vast proportions in this country, and it means a new conception
of law and order regarding the proper placing of the responsibility of the
ill and injured. This new social and economic condition that is upon us,
and growing in vast proportions daily, is of serious moment, especially to
the Medical profession. The present lodge and contract practice has re-
ceived a well deserved censure from us, and has merited a greater condem-
nation than it has received at our hands.
The form of insurance in about one-half of the large countries in Europe
is Compulsory sickness insurance, adopted in Germanv in 1884, Austria,
1887, Report" AMA Hungary, 1891, Norway, 1894, Finland 1895, G. B.
1807, Italy and France 1898, Spain 1900.
U. S. for Federal employees only 1908. About 26 states of the American
union 1911-1913.
OPENING EXERCISES
11
ARGUMENTS
FOR INSURANCE
Real or imaginary conditions in
the U. S. have caused many welfare
and social refonners to organize the
American Association for Health In-
surance evolved from this Associa-
tion as the best method for social
betterment.
Practically every one who has con-
sidered the matter, recognizes that
the distribution of the loss from
sickness by means of insurance is
desirable.
Compulsory Insurance is necessary
because under voluntary insurance
those who need it most are the ones
who remain uninsured (lack of
funds).
Compulsory insurance will stimu-
late the needed campaign for the
prevention of illness.
Life expectancy increases in C.
.between the ages of 18-60 (12
years).
Reduce the time lost by the wage
earner.
Malingering would be negligable
in Comp. Ins.
Disease cause of poverty.
Will solace the abuse of Medical
Charity. Individual will receive less,
but the physician as a whole will re-
ceive more per capita (AMA).
AGAINST INSURANCE
Social evils do exist and some
remedy or remedies should be sought,
but while organized labor, the em-
ployer and the employed and the
physician are opposed and the ones
most vitally interested are opposed
to compulsory insurance. Why is it
best ?
No new health insurance legisla-
tion should be enacted before we en-
tirely rectify the unfairness of the
present comnensation law.
The present system whereby the
poor are treated by the most effi-
cient medical men is far better than
medical service furnished by physi-
cians which H. Ins. obtains.
Untrue — the State bemg already
taxed through sickness, insurance
would not be available.
M. M. Dawson says that this is
not true — the increase was only 1.6
years have non-insured countries a
bstter showing.
This assertion contradicted by ex-
perience. Germany and Austria 6-19
to 9-19, increase A-16.4 increase.
In G. malingering and pension
hysteria has become a regular epi-
demic.
Poverty cause of disease.
Will extend Medical charity abuse
— ^unemployed casually employed.
Self-employed — ^poorly paid in insur-
ance act.
Decrease medical efficiency. De-
stroys incentive for medical research
and individual effort. Competent and
incompetent get same pay. Destroys
personal relationship between patient
and M. D.
To lessen human waste through preventable accidents, occupational dis-
ease, in fact, every preventable that will prevent, is an economical essential
to material busmess, as it is to the human agents that guide it.
Notwithstanding the various pros and cons — we have under the old
scheme 38,000,000 employed in the U. S. and of these 1,385,856 are ill at
any given time — estimating nine days individual loss, gives a grand total
of 12,022,104 sick days in the year.
Now one-half of these illnesses are preventable. To say nothing of
greater and accumulative loss due to a lessened future earning power on
account of illness and the sequel of such illness. It is not an economic
waste to allow it to proceed.
The monetary loss, and the number of sick are important factors and the
State — the employer and the employees are beginning to consider them. as
12 NORTH CAROLINA MEDICAL SOCIETY
Serious problems to be reckoned with. They now realize that the length
of illness and the amount of medical aid is not the object sought, but rather
the complete restoration of the individual to useful citizenship, which ele-
vates the common standard of American physical fitness. Adequate care,
not based on time or money, will be, and should be, insisted upon.
Anything and everything that tends towards raising the general health
standards through preventive or curative measures should deserve serious
consideration, but our ambition to better conditions should not force any-
thing upon us hastily. Wise and judicious council should be sought, prompt
action should be taken, lest we inherit the avoidable mistake of others.
The Insurance acts in the foreign countries and in this country are most
ambitious in an effort to raise the physical standard of a certain class of
laborers — an immense piece of P. H. legislation, based upon certain princi-
ples of Democracy for the benefit of all the people, acceptable by the people,
and for the best interest of the people, the State, the employer and the em-
ployee, each realizing their relative responsibility, will pay a percentage of
the cost, thus distributing the expense.
Under insurance, the annual death rates have been lower in infancy, and
between the ages of 5 to 19. Between the ages of 20 to 39 not steady —
17.7 to 16. Between the ages of 40 to 59 there is a decided increase, 17.6
to 20.8.
If the insurance act will lessen morbidity, mortality and poverty, it will
increase health, happiness, efficiency and prosperity of the insured. Then
by all means, let's have it, but we must remember that the fundamental
factor lies in the intelligence and the integrity of the Medical profession,
and its ability to administer intelligently, adequately and honestly.
There are many objectionable and serious handicaps to the successful ad-
ministration of Health Insurance as handled in the old country, such as low-
ering the standard of the medical profession — the lack of individual inspir-
ation to excel, lack of remuneration for services rendered, etc. All of these
evils should and must be remedied before Health Insurance is endorsed by
the Medical profession. It is your duty and my duty to guide any legislation,
either state or national, that is of such vital importance to the people.
STATE MEDICINE
The greatest asset -in any state lies in the efficiency of the moral, mental
and physical development of her womanhood and manhood.
It is my opinion that health is the basic element of human efficiency, and
upon it stands or falls the power or perfectedness of the state or nation. The
state is constantly and without objection, looking after and controlling her
inferior assets, why then is it not to her greater advantage to seek to raise
the standard of, and to aid in protecting her greatest asset, the human fam-
ily.
There is not a voice raised against the state's efforts towards the preven-
tion of disease, but there has not been a sufficient effort on the part of the
physicians in the prevention of disease, nor in their effort to aid the state in
securing sufficient funds to advance the work, nor pay adequate salaries to
the doctors for services rendered. When, through the activities of the State
OPENING EXERCISES 13
Health Board, there are found to be curables, uncured, operatables, unoper-
ated upon, defects unremedied, focal infections, still infecting — it is high
time for some agencj to be set in motion to correct this existing block in her
progress.
Again, nothing is said when these curables or operatables are among the
indigent — the poorest human asset the state possesses, but a storm of indig-
nation is immediateljf raised when the state begins to protect her great-
est asset, the better element of society.
Illness, injury and deformity, the great factors in inefficiency, suffering,
sorrow, poverty, vice and crime are not limited entirely to the indigent, but
occur throughout the en\tire population.
The surgeon, the internist, the pediatrician, the dentist, etc., have had the
indigent, the ne'er-do-well and the well to do under their professional care
and guidance for years, and those who sought advice have received much,
but by a diliEerent scheme of things. We must be willing to admit that a
great deal more could be accomplished and that through omission rather
than commission, we have rendered a less efficient service. Some form of re-
formation will and should be made, and the present scheme of not differen-
tiating between classes is the best, until we, as Medical men, offer a better
one and one which will accomplish as much, if not more good.
The state can handle its charity, assume the entire expense and accom-
plish much good among her lowest type of citizenship.
The state, by not differentiating, can reach her greater asset and charge
a sufficient sum to save her harmless as to expense, and gain much more by
restoring to health a higher type of citizenship.
Health work is a stupendous problem and upon its continued reformation,
depends the preparedness of everything that lives, and the perfectedness of
everything material.
The value of the physician's superior knowledge in formulating plans, is
essential to its development, as well as to its success or failure. Then it is a
serious question that is confronting us and it behooves us, in fact it is of par-
amount importance that we should properly estimate its value — realizing
that it is to our collective as well as our individual advantage to give it care-
ful consideration. By so doing we will save the dignjity of our profession,
and not be at the mercy of some poorly prepared political scheme.
The Crimean war, the Civil, the Spanish American war, all stand out
with sad histories of having lost more men from bacterial diseases than from
enemies bullets. Contrast this with our present method of prevention of dis-
ease, and we are doubly proud of our late victories in that we conquered the
German and controlled disease. (Controlled the pest and the parasite at
one great blow. )
The preventative measures that have passed the experimental stage, and
that have proven beyond all question their value, were legally enforced in
the army. If these measures are so imperative and essential in the army,
why may I ask, are they not alike imperative in civil life ?
It has been my pleasure to see compulsory vaccination against variola for
the past ten years in school children, and it is indeed gratifying to note the
father, who escaped vaccination, come down with the disease : children, dir-
14 NORTH CAROLINA MEDICAL SOCIETY
ectly exposed, escape infection, and again it is gratifying to see those vac-
cinated against typhoid fever, escape and the stubborn member of the same
household fall ill, thus proving the efficacy of the immunization. Again, it
was a very pleasing experience during this year's epidemic of influenza to
have a school of boys — 140 in number — with not a single case of pneu-
monia. Contrast this with the same school unvaccinated the year previous,
with 50 cases of influenza, 5 severe cases of pneumonia. A school of girls —
130 in number — same prevention — not a single case of pneumonia.
I am sure such instances could be multiplied by us all, yet at the present
time immunization is a voluntary proposition and the general practitioner
'has not immunized his people, nor has he made a strenuous effort. The State
should be empowered, through legislation, to enforce such highly efficacious
measures.
The public health problem is to the casual observer an intangible propo-
sition, and it may yet be some time before the legislators realize its full im-
portance, and appreciate the fact that man is its greatest asset when his mor-
al, mental and physical well being is conserved — and its greatest liability
when these essentials are neglected.
Surely the cow, the sheep, the hog are tangible assets, and the loss of one
is felt by the owner, and effects directly his pocket book. But man has been
made the legislative goat until his efficiency has been so lessened that it has
become retro-active, to the extent that the entire man power has awakened
a new era demanding self perservation, and thereby proclaiming man's effi-
ciency superior to that of the beasts.
Public health work is the prevention of disease, the preservation of health
the prolongation of life, the lessening of morbidity, the lowering of mortali-
ty — through its laboratories, its field workers, its statisticians — has shown
through this method of education that a high standard of health can be ob-
tained. It has also been shown that its conservation has been sorely neg-
lected.
Subjects for immunization have remained unimmunized.
Curables have remained uncured.
Operatables have remained unoperated upon.
To relieve this situation, let the physician wake up to his individual re-
sponsibility and see to it that his clientele comes up to a high standard of
physical fitness. Should the State, through its laboratories, its field workers,
its statisticians, ascertain that a member of a physician's clientele has been
neglected — in that event the state should, and it becomes its duty, to enter
in and protect its defectives.
Any one of the State's agents should make every effort to relieve the de-
fective through the parent, guardian and family.
A monthly report should be made to the county medical society, which
should in turn endeavor to meet the situation. This failing, the State
should take prompt measures for the relief of the sufferer.
There is a clear and distinct duty the State owes to its citizens who are
in need of and have not received medical or surgical treatment. This re-
lief should be given by the best qualified medical and surgical men, who
should receive adequate remuneration for services rendered. This service
should be financed through taxation and with disregard to class distinction.
OPENING EXERCISES 15
Where the individual physician fails to respond to his greater duty to the
community at large, his individual and personal relationship as a family ad-
visor should become a matter for collective action by the community phy-
sicians; otherwise, this situation should be improved through the State.
In conclusion, I would suggest for your attention the advisibility : —
First — the appointing a special committee to prepare a plan for a public
health administration.
Second — The committee shall have the power to associate with itself ex-
perts who are interested in and are well versed in the facts which are fun-
damental to the success or failure of such a plan.
Third — That this committee should act in conjunction with the Ameri-
can Public Health Association, the State Board of Health, the Public
Health Association, the Southern Medical Association.
Fourth — That this committee submit a plan on organization — outline its
administration, and pay especial attention to health supervision and treat-
ment of school children — the handling of the unimmunized — the curing of
the curables — the operating upon the operables, etc.
Fifth — This committee to serve without remuneration, but their actual
expenses incurred shall be paid by this societ}\
SUMMARY
Finally, I would like to quote from the report of the Special Committee
of the A. M. A. for 1919, Social Insurance Series, Pamphlet XI:
"The responsibility, is threefold: communal, industrial and individual.
But the burden today is almost entirely individual. The community has ac-
cepted part of its liability and endeavored, by sanitation, preventive medi-
cine and hospitalization, to improve the situation. Industry has, until now,
evaded its entire responsibility and liability. The individual still bears the
brunt of the burden and the cost of sickness as a personal calamity. The
community and industry have begun to realize and accept their share of the
liability. We have in the past received from southern and southeastern
Europe enormous numbers of hardy, vigorous laborers and industrial work-
ers. We have used them lavishly, and their labor extravagantly. We have
neither wisely harbored their energy nor salvaged the damaged. We have
recklessly used this labor as if the supply were unlimited- We have indeed
treated it as we dealt with our forests and our mines. We have been mining
out our labor and burning it up. Now the war is over, hundreds of thou-
sands of these people are returning to their former homes, not to return
here. This country is facing a scarcity of labor, and must care for it and
salvage it, w^hen injured, as never before.
The remedy for this situation lies economically in a redistribution of costs,
not of adding new costs, but rearranging the present method of expending
the costs already being expended. Large numbers of wage-earners probably
a majority of them, now spend each week enough money on funeral insur-
ance, that they may be sure of a decent burial, which would equal or more
than equal their share of any just sickness insurance scheme to give them
'sick benefits, maternity and adequate medical care, and a hundred dollar
Mineral benefit. Improved medical care must come from more cooperative
16 NORTH CAROLINA MEDICAL SOCIETY
and less purely individualistic care from the medical profession. Free
choice of physician by patient, and present relation of patient to physician,
and just and assured remuneration for work done by the physician can easi-
ly be assured to the physicians under an insurance plan.
Preventive and curative medicine can equally be more fully developed
with free play for individual development of physicians. The alternatives
offered by the funeral insurance companies are a further development of
preventive medicine, state care of the sick by salaried physicians and leaving
the profits of funeral insurance undisturbed."
There is a tremendous problem before us, and we, as medical men, realize
its vast proportions; it does not take a spectacular epidemic of infantile par-
alysis, not the too recent outbreak of Influenza, to make us appreciate the
vast waste of human endeavor, due to the constant but less spectacular dis-
ease.
The laity are accustomed to and accept as a natural law of nature the us-
ual number of deaths, one-half of which are preventable. We have trusted
too much to personal liberity; to the idea that self preservation is the first
law of Nature. In prevention, it has been my experience that self preser-
vation is the last law of Nature.
We inherit, through our profession, the distinction of being the guardians
of the health of our people, and, it is our duty, and should be our privilege,
to safeguard it.
It may not be through Insurance, it may not be through State Medicine :
it must be a remedial measure that will reach all the people all the time.
This remedy should and must come from the Medical profession.
Dr. Parrott: I wish to congratulate Dr. Reynolds on that splendid
paper and that the Society should also be congratulated. In order that it
may receive the attention it should I make a motion to appoint the following
committee — to which the address should be referred to for consideration :
Dr. Laughinghouse, of Greenville; Dr. Long, of Lexington; Dr. Man-
ning, of Durham.
Scientific Papers
SECTION OX PRACTICE OF MEDICINE
SECTION ON CHEMISTRY, MATERIA MEDICA AND
THERAPEUTICS
SECTION ON SURGERY
SECTIONv ON GYNECOLOGY AND OBSTETRICS
SECTION ON EYE, EAR, NOSE AND THROAT
SECTION ON PEDIATRICS
SECTION ON PATHOLOGY, PHYSIOLOGY, BAC-
TERIOLOGY AND ANATOMY
SECTION ON PUBLIC HEALTH AND EDUCATION
Practice of Medicine
REPORT OF TWENTY-FIVE AUTOPSIES ON INFLUENZA
PNEUMONIA
James B. Bullitt
During the Influenza epidemic of 1918 the patients landed from the trans-
ports quickly filled all the hospitals at Brest. It became necessary to ac-
commodate the overflow at the unfinished embarkation hospital at Kerhuon,
three miles away. Base Hospital 65 (a North Carolina unit), with a small
personnel, with almost no equipment and in uncompleted buildings, cared
ior about 3500 patients at Kerhuon Hospital Center during October.
The deaths from pneumonia during that month were something over 600.
Under the conditions existing it was practicable to perform only 25 autopsies
lack of time and the shortage of equipment prevented taking bacteriological
culture and also prevented microscopical study of the tissues at that time.
During the past few months these tissues have been sectioned and are made
the basis of this report. For tissue stains hematoxylin and eosin and eosin-
methylene blue have been used, while the combination of Goodpasture's and
the Weigert fibrin stain (published by MacCallum) has been used for the
demonstration of the bacteria in the tissues. Gram positive cocci occurring
in pairs and in short straight chains are referred to herein as pneumococci.
Several lungs, which in the gross were suggestive of tuberculosis, were also
stained with carbol fuchsin.
The numbers involved are too small to be of much statistical interest,
especially in view of the many extensive reports of the past month. In
many respects these cases accord closely with those reported from other hos-
pitals, but it is desired to call attention to certain points at variance with or
not touched upon in the findings of other observers. All the cases exhibited
a broncho-pneumonia or a lobular pneumonia, with a striking tendency to
confluence. In eight cases this confluence was so great that only the anterior
borders of the lungs and occasional patches here and there seemed to con-
tain air. Such portions were of course markedly emphysematous. Seven
others showed definite lobar consolidation. In four of these the lobular in-
volvement of the remaining portions of the lungs was conspicuous, while in
the other three it was scarcely noticeable in the gross, though quite evident
under the microscope. Only one case was essentially an interstitial pneu- »
monia.
Bacteriological study without cultures from either the living patient or the
autoDsied body is necessarily incomplete and unsatisfactory. But the ex-
cellence of the Goodpasture — Weigert stain is such as to justify some fairly
definite conclusions from the bacteria stained in the tissues. Nothing re-
sembling the influenza bacillus is found in any of these sections. The pneu-
mococcus, occurring in 24 of the 25 cases, is the predominant organism. The
streptococcus appears in but three, and in two of these it is much less numer-
ous than the pneumococcus. The one case in which the streptococcus pre-
dominates showed complete consolidation of the middle and lower lobes of
the right lung, with extensive necrosis. The remainder of the right lung
and the whole of the left lung seemed almost normal in the gross, but mic-
roscopically there is extensive capillary engorgement with slight hemorrhag-e
PRACTICE OF MEDICINE J9
and an extensive but slight interstitial exudate. Both organisms are numer-
ous in the consolidation portion, both are scarce elsewhere. The streptoc-
occi are chiefly in the alveolar walls, the pneumococci about equally distri-
buted in these walls and in the alveolar exudate. In several cases miscel-
laneous bacteria are found which are doubtless postmortem invaders. In
nine cases an unidentified bacillus, morphologically much like the colon bac-
illus but Gram positive, is found. Since these do not appear in the other
organs thus far studied, since they do not occur in the blood vessels but only
in the alveolar exudate and since large numbers have been engulfed by the
leucocytes, it is reasonable to presume that they have played some part in
the pathology. Unfortunately the inability to make cultures renders iden-
tification impossible. It is probably a mere coincidence but the only two
cases in which this organism is more numerous than the pneumococcus are
the only two in which mediastinal and cutaneous emphysema occurred. The
one case in which pneumococcui do not occur died after an illness of thirty
days. His acute symptoms had subsided after about ten days, but a slightly
elevated temperature, a rapid pulse and some prostration continued. His
condition was not considered serious until the twenty-eighth day when he
became dyspnoeic, and cyanotic and sank rapidly. Extensive tough fibrous
adhesions bound both lungs to the parietes. Both lungs were riddled with
small cavities and shot through with old scars. Both lower lobes exhibited
a caseous pneumonia. Fresh exudate consisting of fibrin and endothelial
leucocytes occurs in all parts, and innumerable tubercle bacilli are found
everywhere. It is impossible to distinguish accurately between the damage
done by tuberculosis and that done by the influenza pneumonia. Unless
influenza had stirred a quiescent tuberculosis processs into enormous activity
it is hard to understand how this officer had passed the physical examination
for overseas service only a month before.
The distribution of bacteria presents points of some interest. None are
found in the areas of mere engorgement and hemorrhage, few or none where
the alveoli are filled with hyalin exudate, and few where the exudate consists
chiefly of endothelial leucocytes, lymphocyes and plasma cells ; though they
may be abundant in neighboring areas containing polymorphonuclear leu-
cocytes. When the illness has been of short duration the tissues are teeming
with the organisms, both free in the exudate and enclosed in the leucocytes.
The numbers are greatly reduced after a week, and after three weeks they
are practically limited to pleural exudates and to spots of focal necrosis and
abscesses. This seems to be true even though there may still be considerable
areas of what seems to be fresh exudates, both enterstitial and intraveolar.
The absence of organisms, above referred to, in alveoli containing only blood
and hyalin material might be explained by the view that these represent out-
laying zones of toxic absorption, surrounding foci of bacterial accumulation
and leucocytic exudate. The structural picture in confluent lobular pneu-
monia would seem to accord with this view. But there are numerous cases
in which the foci of lobular pneumonia with leucocytic exudate are rather
widely separated, while all the intervening areas show this tendency to con-
gestion and hemorrhage. The size of these areas and the relatively sharp
transition as we approach the leucocytic zone militate against the idea that
this is merely a part of the lobular pneumonic process. Moreover there is
often a somewhat extensive necrosis, similar to that described by LeCount,
20 NORTH CAROLINA MEDICAL SOCIETY
at considerable distances from the distinct pneumonic foci. It seems legi-
timate to suspect that we ma)' be upon the track of a primary influential
pathology.
A full description of the gross and microscopical picture in this series
would be in large part a mere repetition of the descriptions given by many
others. It is desired to call attention merely to certain points of difference.
Emphasis has been repeatedly laid upon the differences in the inflamma-
tory reaction dependent upon the complicating organism. A more or less
definite correspondence appears to have been established for the tissue
changes in the presence of the pneumococcus, the streptococcus and the in-
fluenza bacillus respectively. Although nearly all the cases discussed in this
paper were clearly of pneumococcic etiology, yet the pathological processes
correspond more closely with those usually associated with the streptococ-
cus. I epitomize one author's excellent description based upon a large ex-
perience with these pneumococcus pneumonias.
1. Pleura smooth; exudate absent or scarcely perceptible, though in late
cases the microscope may show a leucoytic infiltration.
2. Bronchi not conspicuous ; empty or containing fluid ; walls not in-
filtrated; mucosa usually normal.
3. Blood vessels normal.
4. Alveoli contain fluid or a delicate fibrin mesh ; they may be lined with
a hyalin skim ; contain many red blood cells but few leucocytes ; walls nor-
mal or but slightly infiltrated.
In contrast with the above the following outline of my cases could almost
be substituted for the usual description of streptococcus infection.
1. Fourteen showed extensive fresh fibrinous adhesions binding the lungs
to the parietes. These include the three that exhibit the streptococcus as
well as the pneumococcus. Six, including three of the above mentioned
fourteen, had dense fibrous adhesions. In the gross these appeared to be
healed lesions of a previous process, but microscopically the richness in cap-
illaries, fibroblasts and leucocytes indicates that at least four of them are
of recent origin. Three cases (one pure pneumococcus and two pneumococ-
cus-streptococcus) had large pus collections in one pleural cavity. Two
others had from 150 to 200 c.c. of slightly tinged fluid in each pleural
cavity, while several others had smaller amounts of similar fluid.
2. In many the large bronchi were intensely inflamed and contained con-
siderable amounts of muco-purulent material. The smaller bronchi are al-
most invariably full of polymorphonuclear leucocytes; the epithelium us-
ually shows much necrosis, and is often entirely lifted from its base by an
exudate of fibrin and leucocytes. The walls are usually much infiltrated
with leucocytes — chiefly polymorphonuclears but often endothelial leucocy-
tes and plasma cells as well. Very frequently the infiltration and necrosjs
are so marked as to render recognition of the bronchus difficult.
3. Infiltration of the walls of the small arteries is usual. Thrombosis in
both arteries and veins is common, and in late cases organization of these
thrombi is often seen.
4. The alveolar picture is very variable in different lungs and in differ-
ent parts of the same lung. Many places show the appearance characteris-
PRACTICE OF MEDICINE 21
tic of ordinary lobar pneumonia, i. e., well preserved, essentially normal
walls, alveolar cavities filled with a delicate fibrin mesh entangling innumer-
able red blood cells and few or a moderate number of leucocytes. But there
is scarcely a case in this series that does not show wide areas where the al-
veolar walls are greatly infiltrated, often completely obscured, sometimes
by polymorphonuclears, sometimes by endothelial leucocytes and plasma
cells. The air sacs in such instances are packed with similar cells to which
are added the exfoliated epithelium. Frequently the fibrin mesh is not ap-
preciable. In other places a dense hyalin material fills the alveoli, often
seeming to fuse through the walls rendering them scarcely visible. At times
this hyalin seems to have Its origin from fibrin, at times from the fusion of
red blood cells. Both in these hyalin areas and in the areas of intense cel-
lular infiltration necrosis of the pulmonary framework is common. These
necroses may involve only one or two alveoli here and there or may extend
over the greater part of a lobe. Pulmonary abscesses of microscopic size are
seen in nearly every case, while four showed large numbers of cavities vary-
ing from one to five centimeters in diameter. In four others without actual
cavity formation, large areas involving from one-fourth of a lobe to a whole
lobe were soft, gray and friable, tearing from a touch of the finger. Micro-
scopically these areas are completely necrotic, the pulmonary framework be-
ing scarcely recognizable and the whole mass consisting of disintegrating
cells and granular debris. Bronchiectatic dilatations are common.
5. Marked tendency to organization is usually regarded as characteris-
tic of infection with streptococcus or the pheiffer bacillus rather than the
pneumococcus. In my cases however there is scarcely any one feature more
striking than the rapid and extensive fibrosis. In every case surviving as
much as a week this process becomes evident ; in those living three weeks it
is very prominent. The alveolar walls and intraelveolar exudate, the bron-
chial w^alls and to a lesser extent the bronchial exudate, the vascular walls
and thrombi, all are involved. It is not uncommon to find nodules resem-
bling tubercle or small gummata. Sometimes a thin capsule of newly formed
connective tissue surrounds a soft granular necratic mass. Sometimes the
whole nodule has become organized. In some cases large areas of pulmon-
ary tissue are completely obliterated. In two men living about five weeks
the condition is particularly interesting. Each of these had entered upon
apparent convalescence after an acute illness of about ten days. Although
physical examination showed no especial reason why they should not recover,
yet they did not regain strength, their pulse rates continued rather high and
very slight effort produced dyspnoea and cyanosis. One sank gradually
with a steady increase of the symptoms above described. The other seemed
to be improving. The night nurse reported him in good condition at 4 A.
M. He was found dead in bed at 5 A. M. No embolus nor other cause
for the sudden death could be found. Both cases showed a slight degree of
chronic myocarditis. There was scarcely any acute patholog}^ remaining in
the lungs, but the extreme condition of fibrosis left little serviceable pulmo-
nary- tissue. The picture suggests an analogy to those cases of nephritis in
which recovery from the acute disease is followed by a fatal crippling from
the repair processes.
The presence of large amounts of pigment from distintegrated hemoglobin
is to be expected in lungs with such extensive hemorrhage. It is uniformly
22 NORTH CAROLINA MEDICAL SOCIETY
present in this series, often in such quantities as render difficult the search
for bacteria in the tissues. Sometimes every endothelial leucocyte is loaded,
many polymorphonuclears contain goodly amounts, and much is free in the
exudate. I have been constantly impressed with the large quantity of this
pigment, not only in the lungs but also in the heart, liver, spleen, kidney
and other organs. In the kidney it is contained partly by endothelial leu-
cocytes; but most of it appears in the epithelium to some extent in that of
Bowman's capsule and the convoluted tubules, but especially in the cells
lining the ascending tubes of Henle and the collecting tubules. It occurs
chiefly in the basal portions of these cells.
As in the epidemic elsewhere necrosis and hemorrhagic inflammation of
the rectus abdominus muscles was common in our hospital. There were two
cases among those autopsied. I have not seen mention of, similar myositis
in other muscles. In one of my cases it occurred in moderate degree in the
serratus magnus. Severe pain in the right side had caused suspicion of
empyema. Needle puncture gave negative results. At autopsy the pleura
was normal, but over a space of two or more inches in diameter the muscle
was soft and dark in color. Microscopically there is a moderate hyalin
necrosis, a small amount of hemorrhage and a slight leucocytic infiltration.
This suggests a possible explanation for the localized pains in the back, sides
and elsewhere that are so often troublesome a long time after recovery from
influenza. I have in mind three men of our personnel who had not been
seriously ill with influenza but who were largely incapacitated for several
months afterward with muscular pains, in the left calf, the left hypochar-
dical and right scapular regions respectively.
A CASE OF EVENTRATION OF THE DIAPHRAM
W. Allen, M. D., Charlotte, N. C.
Eventration of the diaphram, sometimes known as dilatation, insufliciency,
"hochstand", or elevation of the diaphram denotes a condition in which
half the organ is thinned out and distended, rising high into the thoracic
cavity with corresponding upward displacement of the abdominal viscera
on the affected side. There is no break in continuity as in diaphranatic
hernia.
The subject has been well reviewed in our literature by Sailer and Rhein
(1) in 1905 and particularly by Bayne-Jones (2) in 1916, so that no ex-
tended review will be given here. The latter collected 45 cases, only four
of which had been reported from this country. Aronson (3) reported a
case in 1916 which with the present case makes a total of 47 cases. In
four instances the right side was affected, in forty-four the left. Eppinger
(4) has shown that the ratio of eventration to hernia of the diaphram is
about 1.37.
Cruveilhier (5) considered the condition secondary to disease of the
phrenic nerve, of the diaphramatic muscle, or abdominal disease causing un-
equal pressure on the two sides of the diaphram; but most subsequent ob-
servers have adopted Thoma's (6) view, that eventration is an anomaly
caused by defective development. Bayne-Jones points out that pregnancy,
the commonest cause of abdominal distention, has not been associated with
this condition (only 8 out of 43 adults were females) ; that it has been found
PRACTICE OF MEDICINE 23
in tour foetuses or young children, and that in nine of the fort_v-five cases
which he reviews, other developmental anomalies were present.
Aronson's case had Hirschsprung's disease, and the case here cited had
bilateral inguinal herniae.
Post mortem examination has shown the affected half of the diaphram re-
duced practically to a thin fibrous sheet with almost no muscle tissue re-
maining. The dextro-cardia, which has heretofore invariably been founds
in eventration of the left side has generally been attributed to mechanical
displacement of the heart and mediastium by the bulging up of the diaphram.
Sailer and Rhein take issue with this view, showing that the elacticity of
the right lung is more important, and citing a number of cases of displace-
ment of the heart to the left with hypoplasia of the left lung, both with and
without elevation of the diaphram. In the present case the heart was not
displaced to the right but directly upward.
The left lung is not compressed, being only partially developed, at times
showing incomplete division into three lobes. The development of the
thoracic walls is normal. Below the diaphram, developmental anomalies
of the colon and mesentery have been found with a varying amount of up-
ward displacement of the abdominal viscera.
These cases may have no symptoms referable to the diaphramatic condi-
tion ; some have cough and dyspnea, probably due to cardiac displacement ;
others have gastro-intestinal symptoms.
On physical examination lagging of the left side with displacernent of
the apex beat will be seen. The lower left chest is usually tympanitic with
absence of breath sounds, and fremitus, and Litton's sign. In Sailer and
Rhein's case the lower left back was dull because of an enlarged spleen. In
the present case the lower left chest was dull possibly from the same cause
or from a preceding tubercular pleurisy.
The Roentgenological examination has been well set forth in Becker's
(7) article. When the distended stomach fills the left lower thorax, the
clear area is free from the usual pulmonary markings and its upper surface
is bounded by a smooth elliptical line. Fluoroscopic examination shows
this line to be the diaphram, which during respiration may reveal the left
half contracting normally or paradoxically.
Eventration is apt to be mistaken for hydro-pneumothorax and needled,
and the differentiation between eventration and hernia of the diaphram is
at times extremely difficult.
Case Report; — A real estate agent, aged 31, single, was referred for ex-
amination Feb. 7, 1916, by Dr. R. L. Gibbon. His mother had died at
51 of stomach trouble; a brother, who had had no disease, had never been
strong; two brothers had died in infancy. The patient at the age of seven
had nearly died with dysentery lasting a month. No other illness until the
age of 24, when he had a fever of ten day's duration, called malaria. Had
no chills with this, but during this fever developed a cough which he has
had ever since. Five years ago took a cure for alcholism, and has abstained
since. Chews and smokes. Had gonorrhea and venereal herpes some years
ago. Two years ago had a nervous breakdown and stayed in bed two
months. Four years ago, after cranking his car, felt a sharp pain In right
lower abdomen, and found he was ruptured slightly on both sides.
24 NORTH CAROLINA MEDICAL SOCIETY
At present complains of general weakness, walking up hill brings on dysp-
nea and cough and at other times pain over sternum. If he lean forward
and coughs, the upper abdominal muscles, at the costal margins, will con-
tract violently leaving lumps which he has to massage until they disappear.
Coughs some at night and on rising, and brings up an ounce or more of
purulent sputum in the morning. No night sweats in four years. Has
dumb chills in spring and fall and on damp days, with enough fever to make
him sit close to a stove. Before his fever seven years ago, he weighed 135
pounds, and now weighs 105 pounds. Appetite good. Sleeps very poorly,
averaging three hours a night. No gastro-intestinal or genitourinary symp-
toms. His cough, dyspnea, weight, and weakness have not varied much in
the past seven years. He takes no exercise, has few amusements, works
steadily and worries a great deal.
Physical Examination: — A small, weak, pale, thin man. Eyes and
throat normal. Epitroclear and left posterior cervical glands enlarged.
Skin dry and looks transparent. Chest ; The lower left side seems smaller
than right and lags on respiration. The right side is hyperresonant through-
out, with small moist rales under middle third of scapula behind. The re-
sonance over the upper third of the left side is considerably less than the
right side, but has no tympanitic quality. The lower half of the left front
is tympanitic ; the lower two-thirds of the left axilla and the lower half of
the left back are flat. Breath sounds harsh and broncho-vesicular over up-
per half of left side, absent below. No rales. Voice sounds and tactile
fremitus absent over lower half of left lung. Abdomen flat, nowhere tender,
thin walled ; liver dulness normal and spleen not palable. Both inguinal
rings are weak and stretched with small incomplete herniae, direct on the
right, oblique on the left. The femoral rings bulge considerably on cough-
ing. Extremities and genitals normal. Superficial and deep reflexes nor-
mal. Joints normal ; there is a moderate spinal curvative with apex oppo-
site the left scapula; this does not modify the mobility of the vertebral col-
umn. Apex beat in midclavicular line, third interspace, left. Heart size
and sounds, rate and rhythm normal. Blood pressure 118-80.
Laboratory Examination: — Haemoglobin 75%. White count 14,800.
Polynuclears 72%, lymphocytes 17%, large mononuclears 7%, eosinophils
2%, basophils 2%. Red count 4,800,000. No plasmodia. Shape and stain-
ing reaction of red cells normal, some variation in size. Wassermann
strongly positive.
Urine acid, 1023, negative for albumen, sugar, indican ; microscopically
negative.
Feces negative for eggs and protozoa.
Sputum showed tubercle bacilli.
Roentgen Examination : — The plates showed on the right side a tuber-
cular focus below the right apex, corresponding with the moist rales heard
in this area. The left side showed over the lower half of the chest a uni-
formly dense shadow bounded above by a smooth curved line, level with the
sixth rib behind and fourth in front. The heart shadow was high and
largely behind the upper end of the sternum. (The Roentgenograms were
made by the late Dr. J. W. Squires and unfortunately destroyed after he
entered the army.)
PRACTICE OF MEDICINE 25
Under the impression that this was a left pleural effusion the left back
was needled, but no fluid obtained. The needle, inserted in several places,
seemed to be always in solid tissue. A fluoroscopic examination now demon-
strated that the smooth upper border of the left chest shadow was the dia-
phram which could be seen contracting normally on inspiration. The car-
diac contractions could be seen above this, from the third interspace to the
sternal notch. Gastro-intestinal plates revealed no abnormality and a cor-
rected diagnosis of eventration of the left side of the diaphram was made.
The patient died a year or so later from pulmonary tuberculosis.
The two unusual points in the case were the displacement of the heart
dirc'^tlv upward, and the dulness in the left lower back and axilla which
may possibly have been due to an enlarged spleen as in Sailer and Rhein's
case, or to a previous tubercular pleurisy.
References:
(1) Sailer. ].. and Rhein, R. D. ; Amer. Jour. Med. Sc, 1905,
CXXIX, 688.
(2) Bayne-Jones, S., ; Arch. Int. Med., 1916, XVII, 221.
(3) Aronson, E. A.; N. Y. Med. Jour.. 1918, CVIII, 196.
(4) Quoted by Bayne-Jones.
(5) Cruveilhier: Traite d'Anatomie pathologique generale, 1849, II,
617.
(6) Thoma, R. : Virchows Archiv., 1882, LXXXVIII, 515.
(7) Becker, T. : Fortschr, a. d. Geb. d. Roentgenstrahlen, 1911. XVII,
183.
X-RA^ FINDINGS IN THE LUNG FOLLOWING INFLUENZA
TUBERCULOUS AND OTHERWISE
Dr. R. p. Noble, Raleigh, N. C.
Numerous patients are presenting themselves to the general practitioner
and specialist, following an attack of influenza with varying symptoms,
some complicating the chest and others without apparent chest symptoms.
The cases are very often referred to the roentgenologist for his opinion of
the pre*sent lung condition and an x-ray examination follows. Before I go
further, let's get clearly in mind what has taken place in the lung of the
influenza pneumonia subject.
Lung involvement complicating influenza is a most severe type of infec-
tion and produces tissue changes in varying degrees, in trachietis, trachio-
bronchitis, broncho-pneumonia and pneumonia. From the microscopic ex-
amination of infected lungs of monkeys in which the influenza bacillus had
been directly applied to the mucous membrane of the nose and throat, pro-
ducing the same symptoms as influenza pneumonia in man ; and of human
lungs following death from influenza pneumonia there was found exten-
sive hemorrhage, peri-bronchial areas of consolidation with an exudate of
leucocytes, mono-neucler cells and desquamated alveolar epithelium and
thickening and infiltration of the alveolar walls. There were considerable
patchy emphysema of the periphreal lobules. The pleural surfaces were
rarely involved. This amount of inflammation caused certain thickening and
26 NORTH CAROLINA MEDICAL SOCIETY
tissue changes that cast an x-ray shadow. It remains for the roentgenologist
to find and properly interpret from the x-ray plates evidences of these patho-
logical changes. The x-ray examination during or immediately after an at-
tack of influenza pneumonia shows nothing beyond the well known opacity
of a pneumonia lung and is of little value.
Only a small proportion of the cases give a history of having had any
lung trouble previous to the attack of the influenza. The lung infection at
the time of the pneumonia so lowered the bodily resistence, enabling a latent
tuberculous foci to exert itself. It is this tuberculous complication which
requires our most careful investigation. The previous inflammatory condi-
tion has produced a general thickening of the lung tissue so that a hazy ap-
pearance is given to the x-ray plates.
These tuberculous conditions verj^ often affect the periphery of the lung,
giving a fan like appearance of increased density. The apices, one or both,
are frequently affected, showing ;i cloudiness and sometimes contain-
ing a faint floculent looking mass of tuberculous deposits, having the appear-
ance of half cooked oatmeal. These soft tuberculous deposits may be seen
anywhere in the lung and are often widely separated. Heavy hilus shadows
and otherwise dense calcifications indicate a condition of long standing. It
often happens that a slightly increased density of a soft tuberculous mass will
develop in the area of a previous pneumonia consolidation. There will be
noticed perfectly normal lung near an erea of increased density and the
comparison is apparent.
In these cases in which there is evidence of tuberculous deposits there is
one sign that is worth all the others. If the costal and sternal cartilages of
a young person are heavily calcified, or show the deposits isolated, indicating
a sufficiency of lime salts in the blood, the tuberculous infection if seen (and
it generally will be in these cases) will be cared for under proper treat-
ment.
Now, on the other hand there are lungs that have not fully recovered
from the influenza attack and coupled with certain nervous and digestive
disturbances give many and varied symptoms- No tuberculous deposits are
seen in these lungs, though there is a general haziness not seen in otherwise
normal lungs. The areas most affected during the influenza illness show
more pronounced haziness and often a mottling, approaching in appearance
the tuberculous mass. This condition is seen at an earlier date after the ill-
ness than does the tuberculous deposits and does not hold on or increase,
whereas the tuberculous area becomes more pronounced. The walls of the
bronchial tubes are thickened and the bronchial and peri-bronchial glands
show increased shadows. The priephery of the lungs and the apices are less
frequently involved while the central and lower portions contain more of
the shadows. Both lungs are generally involved. These findings are to be
thought of as a normal lung following such a marked inflammatory reaction
during the previous illness. Many normal lungs show shadows caused by
some previous lung infection, but we have come to regard them as norma!
lungs at the present time, having fully recovered but still showing the marks
of the infection. But these normal lungs show more clear cut, definite
shadows and the haziness has disappeared. The object of this paper is to
show the importance of careful lung examination with the x-ray following
PRACTICE OF MEDICINE 27
the influenza pneumonia cases and the appearance of the tuberculous and
non-tuberculous lung.
As complications following influenza pneumonia we also get pleurisy
with effusion, empyema and empysematous areas but they are more easily
noted and will not be discussed in this paper.
In studying the lung plate there are many conditions to be dealt with
and it is not necessary that the roentgenologist do the ground hog stunt, for
in the case of seeing no shadows to frighten him he may be caught out in
some unpleasant season : yet if he runs from every shadow he sees and re-
treats he will miss many of the beauties of the next forty days.
There are shadows and if correctly interpreted will help in the proper
diagnosis and subsequent treatment.
PRELIMINARY REPORT ON A STUDY OF THE
GOETSCH TEST
Dr. R. AIcBrayer, Clinician and Director of Laboratories, North
Carolina Sanatorium, Sanatorium, N. C.
This study has been undertaken with the hope that out of it may come a
more practicable test for the busy practitioner of today who in my opinion
does not have the time to devote to such a lengthy technique as is used by
Dr. Goetsch. We think that we have gotten very satisfactory results from
this test during its use of six months or a little longer by us. Let me say in
the beginning that to the men who have the time I would strongly advise
their utilizing the test as laid down by Dr. Goetsch. I believe it is based on
fundamental physiologic principles and in the right hands will certainly
give accurate results.
First let us review the Goetsch Test or better termed "The Adrenalin
Hypersensitiveness Test." The following is an extract of a paper published
by Drs. Norman Clive Nicholson and Emil Goetsch of the Trudeau Sana-
torium, Trudeau, N. Y., under the heading of "The Differentiation of Ear-
ly Tuberculosis and Hyperthyroidism by Means of the Adrenalin Test,"
•Which article was published in the American Review of Tuberculosis, vol-
ume 3, No. 2, April, 1919. Dr. Goetsch has been using this test for about
five years during which time he has had many of his positive findings to
come to operation where, he claims, the accuracy of the test has been "con-
firmed by operation and microscopic study of the gland tissue."
The technique of carrying out the test is as follows :
"We want the patient to be as calm and restful as possible before the test
so that the reaction to the adrenalin will stand out sharply in contrast.
Accordingly the patient is put to bed the previous day and is reassured by
the attending physician that the test will be in no way painful or associated
with any danger. At this time, too, the standard case-history is supplement-
ed by a history taken with special reference to symptoms of thyroid disturb-
ances. One must determine the presence or absence of nervousness, throb-
bing, tachycardia, tremor, depressions, crying spells, struma, apprehensions,
hot and cold flushes, cold hands and feet, fainting spells, memory lapses,
dermatographism, amplified by a detailed scrutiny of the signs suggestive of
Zb NORTH CAROLINA MEDICAL SOCIETY
hyperthyroidism, such as positive eye-signs, (Joffroy, Moebius, von Graefe
and Dalrymple) tremor, struma, thrills or bruits over the thyroid, throbbing
of the carotids and of the abdominal aorta, the condition and distribu-
tion of the hair, and slight edema of the eyelids, legs or hands. In this con-
nection it should be borne in mind that hyperthyroidism may exist with
negative eye signs and only indefinite clinical findings in the thyroid gland.
Consequently we feel that the response to adrenalin is a much more de-
pendable criterion of hyper-activity of the gland.
"On the day of the test the patient is placed as nearly as possible under
normal conditions. By this we mean in a warm room without the appli-
ances such as hot water bottles, heating devices, etc., which are common to
the outdoor treatment of tuberculosis. The patient, of course, is to take
his meals in bed. We emphasize these precautions because of the well-
known hypersensitiveness and irritability of hyperthyoid and tuberculous
patients. Because of the tendency of the thyroid to hyperactivity at the
menstrual period the test is not given during this time.
"We proceed with the test as follows:
"Two readings are taken, at five minute intervals, of the blood pressure,
systolic and diastolic, pulse rate and respiration. A note is made of the
subjective and objective condition of the patient. This includes the state
of the subjective nervous manifestations, the throbbing, heat and cold sen-
sations, asthenia, and the objective signs, such as pallor or flushing of the
hands and face, the size of the pupils, throbbing of the neck vessels, and
precordium, tremor, temperature of the hands and feet, prespiration, and
any other characteristic signs or symptoms noticed. These signs are all
noted previous to the injection of the adrenalin so that comparison may be
made after the injection.
"A hypodermic syringe armed with a fine needle which, when inserted,
causes little discomfort, is then used to inject 0.5 cc. (7.5 minims) of the
commercial 1-1000 solution of adrenalin chloride (Parke, Davis & Co.)
into the deltoid region, subcutaneously. Intramuscular and intravenous in-
jections are not given. Readings are then made every two and one-half
minutes for ten minutes, then every five minutes up to one hour, and then
every ten minutes for half hour or longer. At the end of one and a half
hours the reaction has usually entirely passed off, sometimes earlier. The
repeated early readings are made in order not to miss certain reactions on
the part of the pulse and blood pressure that may come on in less than five
minutes after the injection is made. This is particularly true of cases of
active hyperthyroidism.
"In a positive reaction there is usually an early rise in blood pressure and
pulse of over ten points at least; there may be a rise of as much as fifty
points or even more. In the course of thirty to thirty-five minutes there is
a moderate fall, then a second slight secondary rise, then a second fall to
the normal in about one and one-half hours. Along with these one sees an
exaggeration of the clinical picture of hyperthyroidism brought out, es-
pecially the nervous manifestations. The particular symptoms of which the
patient has complained are usually increased, and in addition there are
brought out many symptoms which have been latent. Thus it is not uncom-
mon to have extrasystoles brought out, after the injections of the adrenalin.
PRACTICE OF MEDICINE 29
The patient is usually aware of them and may tell one that she has felt this
same thing a year or two previously, at which time the symptoms of the dis-
ease were more active.
"The following may all or in part be found: increased tremor, appre-
hension, throbbing, asthenia, and in fact an increase of any of the symptoms
of which the patient may have complained. Vosomotor changes may be
present ; namely, an early pallor of the face, lips and fingers, due to the vas<j-
constriction, to be followed in fifteen to thirty minutes by a stage of vaso-
dilation with flushing and sweating. There may be a slight rise of temper-
ature and a slight diuresis.
"In order to interpret a test as positive we have regarded it is as necessary
to have a majority of these signs and symptoms definitely brought out or in-
creased. Thus there is at times a considerable increase of pulse rate with-
out much increase in systolic blood pressure, but with a considerable in-
crease or exacerbation of the objective signs and symptoms ; or there may
be an increase of ten points in the pulse and blood pressure and a moderate
increase of the symptoms and signs; or again, there may be only slight
changes in pulse and blood pressure and considerable change in signs and
symptoms. These may be regarded as positive. In a word, then, one must
consider the entire clinical picture produced in order to gain a correct in-
terpretation, just as in the disease itself one cannot expect every one of the
characteristic signs and svmptoms to be present in order to make a diagno-
sis."
In the beginning I stated that in my opinion this test was based on physi-
ologic truth. A slight review of your knowledge of physiology and phar-
macology will show you that the secretion of the thyroid glands, be it iodo-
thyrin, thyroiodin or whatever it may be, is a stimulant to the autonomic
nervous system. Now when this system is continuously bathed in this toxin
of hyperthyroidism it becomes hypersensitive. Another look at your phar-
macology will tell you that adrenalin is the quickest and most practical ob-
servable drug in its action that we possess for stimulating the autonomic
nervous system. With this in mind adrenalin is the drug for this use. Too,
you will agree with me that it is perfectly plain that w^e have a need for
such a test for how many times do we find a case of tuberculosis we call
hyperthyroidism or how many times we find a cause of hj'^perthyroidism that
we call tuberculosis? Only a glance at our previous errors will prove that
we have a serious need for such a test as this and most welcome will it be if
this is it. As stated above I am of the opinion that Dr. Goetsch's test is
impracticable for the busy general practitioner of North Carolina and for
that reason the following studies have been undertaken with the hope that
out of them may come a more practical test for the general practitioner.
This preliminary report is upon a study of a series of fifty-five patients.
Five normal persons, twenty having tuberculosis in different stages but hav-
ing no signs or symptoms of hyperthyroidism, twenty-two suspicious thyroids
having tuberculosis and six tuberculous patients known to have hyperthy-
roidism. We have taken the following list of symptoms and signs of hyper-
thyroidism and have classified these findings in each case under the follow-
ing headings: Systolic blood pressure, diastolic blood pressure, pulse pressure,
pulse rate and quality, tremor, nervousness, palpitation, diuresis, temperature.
30 NORTH CAROLINA MEDICAL SOCIETY
respiration, apprehension, pupilary changes, vasomotor changes in face, hands
and feet and sugar in the urine. I could not think of taking up your time by
reading the tabulation, as interested as I am in it. For that reason I will
proceed to make a comparative study of these signs and symptoms. In each
of the four classes of patients named above, systolic blood pressure rose prac-
tically the same number of points reaching its maximum in the known
cases of hyperthyroidism in nineteen minutes, having a secondary rise in
forty-one minutes and remaining above normal for an average of an hour
and seventeen minutes. In the twenty-two suspects the systolic blood pre-
sure rose to its maximum in an average of eighteen minutes. In four sus-
pects, the systolic blood pressure made a second rise in thirty-nine minutes
and remained up for an average of fifty-nine minutes. The other eighteen
cases of this suspect group reached their highest in thirteen minutes and re-
turned to normal in twenty-three minutes. The twenty "no hyperthyroids"
reached their maximum systolic blood pressure in an average of 11.5 minutes
and returned to normal in an average of twenty-two minutes. The normal
class reached its maximum systolic pressure in seven minutes and returned
to normal in nineteen minutes.
Diastolic pressure: In the "known hyperthyroids" the diastolic blood
pressure fell seventeen points, the maximum fall corresponding in minutes
to the maximum rise in systolic pressure and continued in the same propor-
tion until a normal level was reached by the systolic pressure. In the same
four suspects mentioned above the diastolic blood pressure fell sixteen points
with the maximum systolic rise and returned to normal along with the
systolic blood pressure. In the other eighteen cases the diastolic blood, pres-
sure fell an average of nine and one-fifth points corresponding to the maxi-
mum systolic rise. It also returned to normal with the return of the systolic
pressure to normal. The "no hyperthyroids" gave a diastolic fall of seven
points which occurred at the same time as the maximum systolic increase
and returned to normal therewith. The normals had a fall of six points
in diastolic blood pressure corresponding to the maximum systolic rise and
returned to normal with that of the systolic.
Pulse pressure: The "knowns" had a maximum increase of fifty-six points
which pressure returned to normal with the systolic pressure. Four suspects
had an increase of forty points while eighteen suspects had an increase of
twenty-nine and one-half points. The class of "no hyperthyroids" had an
increase of thirty-one points while the normals had an increase of twenty-
eight points.
Pulse: In the "knowns" the pulse rate increased an average of twenty-
seven points. In four suspects there was no increase or decrease. In
eighteen suspects there was an average increase of fifteen points (maximum
increase thirty, minimum increase six.) The "no hyperthyroids" had' an
increase of fourteen points while the normals decreased three points per
minute.
Quality: In the "knowns" the pulse became irregularly, unequal and
varied in volume. Fourteen suspects had the same type of pulse while
eight had a normal, full, well rounded pulse. In the "no hyperthyroids" the
pulse was equal and regular in sixteen cases but there was a slight irregulari-
ty present. In the normals the pulse was full and bounding, no irregulari-
ty or inequality was detected except slight inequality in one case.
PRACTICE OF MEDICINE 31
Tremor : Tremor was increased in every case in the series as well as
was nervousness. Palpitation was present in each case of the series and slight
diuresis was present in all. A temperature increase of three- fifths of a de-
gree in the "knowns" was found reaching its highest at the end of forty-
seven minutes. It increased in all suspects an average of two-fifths of a
degree reaching its highest in an average of forty minutes. In the "no hy-
perthyroids" temperature was increased two-iifths of a degree reaching its
highest in forty-two minutes. In the normals the temperature was increased
an average of one-lifth of a degree reaching its highest in forty-six minutes.
Respiration: In the "knowns" this was increased an average of five
points. In six suspects increased an average of four points. In sixteen sus-
pects increased an average of two points. In the "no hyperthyroids" it in-
creased an average of one point and in the normals decreased an averagv. jf
one and one-half points.
Apprehension : This was increased in each case of the series.
Pupilary changes: These changes were present in the w^hole series
though in the six "knowns" and in three suspects there were frequent pupi-
lary changes. In all others there was a primary slight dilitation followed
by an early return to normal.
Vasomotor changes: These were present in the hands, feet and face of
the entire series.
Sugar in the urine: None was found in any specimen.
Conclusion : I frankly state that as yet I do not consider this small
amount of work reported upon as sufficient evidence for warranting any de-
finite conclusions. However, if future studies substantiate these findings
we will find that the differential diagnosis of tuberculosis and hyperthy-
roidism will be made easier for the general practitioner of our state when
after the subcutaneous injection of adrenalin he finds, between fifteen min-
utes and one hour and thirty minutes after the injection, the following:
First: A systolic blood pressure rising ten or more points and remaining
above normal for fifty minutes or more.
Second: Increased pulse rate of ten or more points per minute propor-
tionate to the systolic rise.
Third : An increase of pulse pressure of thirty-five or more points.
Fourth : Pulse irregular and varying in volume.
Fifth : An increase in respiratory rate of four or more points per min-
ute.
Sixth : Varying pupilary changes.
1 firmly believe that this test can be made more practical for the general
practitioner and for that reason we are diligently pursuing these studies at
the State Sanatorium and hope to have at a future date some more definite
and positive report to make. Again let me state that this paper is not a
rriticism of the work done by Dr. Goetsch, for, as I stated above, if any
doctor has the time certainly the thing in my opinion for him to do is use the
Adfenolin Hypersensitiveness Test verbatim as given in Dr. Goetsch's
technique which I read to you in the beginning.
32 north carolina medical society
Discussion of Dr. McBrayer's Paper
preliminary report on a study of the goetsch test
Dr. W. deB. MacNider, Chapel Hill: I wish I were in position to
discuss from a clinical point of view the validity of this test. I can not do
that, because I am removed from clinical medicine, but I would feel asham-
ed of myself if I did not get up here and congratulate Dr. McBrayer, Sr..
on having a son who is sufficiently interested to make use of the material at
hand and get up such an excellent paper. It is a thing that many of us
could do and ought to do.
ESSENTIAL HYPERTENSION
Dr. R. F. Leinbach, Charlotte, N. C.
Some time ago my attention was attracted to an article appearing in tiie
Journal of the A. M. A., written by the former Chief Cardiovascular and
Lung Examiner of the Medical Officers Training Camp, Camp Greenleaf,
Ga., in which certain personal views and opinions concerning the nature and-
relations of blood pressure were set forth. I was impressed with the fact
that certain of these views were at variance with what I regarded as the
sanest teachings on this subject. Though much less common than in for-
mer years it is still not remarkable now and then to encounter somewhat
radical and iconoclastic theories in the literature regarding medical condi-
tions of unproved nature. However, this article served to impress on my
mind the divergence of opinion obtaining today after fifteen and more
years of study and observation concerning the nature and relations of blood
pressure.
I do not expect to clarify any of the unknown elements in hypertension
but merely to present a few phases of the subject in such relations as seem
warranted by a careful review of the literature of the past eight or ten years.
Doubtless to a certain extent the discordance of opinion with regard to
the nature of hypertension has been contributed to by the varying names
under which the subject has been presented, none of which has gained a
wide spread currency; and again to the lack of a suitable clinical classifi-
cation. It is a striking fact that in everyday intercourse among medical men
and even in consultation work one chooses to refer to this or that patient as
"a case of nephritis with high blood pressure" or "a case of arterial sclerosis
with high blood pressure" or simply as "a case of high blood pressure" rather
than to venture to designate it by any particular descriptive term based on
the probable type of pathology. This I take it is often an evidence of wis-
dom as it is often difficult and sometimes impossible to predict the type of
pathology which autopsy will reveal, from symptoms presenting during life.
This is of course especially true in dealing with nephritis.
From the work of Gull and Sutton in 1872 on the pathology of Bright's
Disease came a term highly descriptive of the pathology- found in certain
cases of permanent high blood pressure — namely, Arterio-capillary fibrosis.
The appropriateness of this term based on the pathology of a certain type of
the disease, namely a diffuse fibrosis of the smallest arterioles not limited to
the kidney, is, I think, unquestioned today, yet one rarely encounters the
term in diagnosis. Dr. Theodore Janeway, while still at Columbia Uni-
PRACTICE OF MEDICINE 33
versity, New York, published the first analytical study of a large series of
clinical cases of high blood pressure in this country under the name "Pri-
mary Hypertensive Cardio Vascular Disease." This term he continued to
use in his later writings until his death. But for its awkward length it is
one of the most satisfactory terms yet offered in that it excludes all secon-
dary hypertensions if such there be, and yet admits of sufficient variation in
pathology to be clinically applicable in diagnosis. Sir Clifford Albutt's
term of "Hyperpiesis", descriptive only of the dynamic phenomena of the
disease in the early stages, is inadequate and indeed scarcely ever encount-
ered in the literature of this country today. It is worthless as a diagnostic
term.
The Hopkins School, in general, employs the term Cardio- Vascular-Re-
nal Disease in essays on the subject, though recently Mosenthal of Hopkins
and some other writers elsewhere have begun to employ the term "Essen-
tial or Benign Hypertension." The term is borrowed from the German of
Volhard and Fahr who in 1914 described the benign uncomplicated type of
high blood pressure. It is true that many hypertensive cases run a practi-
cally symptomless course for years, and to such it may be entirely appropri-
ate to apply this term. It is to be sure a very acceptable term in naming the
disease to the unhappy subject of a high blood pressure, and by suggestion
is more useful in quieting his state of apprehensiveness as to his early disso-
lution than a multitude of words and explanations. As a medical diagnos-
tic term it can have no great value or permanence. The pathology is that
of the old Gull and Sutton type of arterio-capillary fibrosis of mild grade.
Since we know practically nothing of the physiologic mechanism which is
productive of states of permanently high blood pressure we cannot deny
that it is possible that this mechanism may be set in action by different
causes or by various chemical substances present in the blood stream or else-
where and thus may be a secondary condition. In accordance with this pos-
sibility and in harmony with our desire to ascribe a cause for all observed
morbid symptoms we are accustomed to speak of arterial sclerosis, renal scler-
osis, cerebral sclerosis as cause of high pressure. Yet one cannot doubt that,
there is a definite underlying unity in the various types of high blood pres-
sure seen and that the earliest observed manifestation in all types is the hy-
pertension itself. For a time the statement that a regional vascular sclerosis
was the cause of high pressure was considered sufficient but there are many
able minds who now hold the view that these sclerotic changes in the blood
vessels are the result and not the cause of the hypertension. To this view
were committed vonBasch and Jores in Germany, Huchard in France, Al-
butt and many others in England, Janeway in this country while Dr. Bar-
ker in 1917 at the Atlanta session of the Southern Medical Association ex-
pressed his views as follows:
"No matter how important a contributing factor to the hypertension the
arteriolar sclerosis may be in advanced cases, either as offering a mechanical
obstruction to the circulation in the kidneys (or in the viscera generally),
or as leading to toxic vaso-constriction by injuring the kidney and causing
retention of metabolic constituents that are normally eliminated, I can but
think that the origin of the initial hypertension must be sought elsewhere."
Practically all authorities are agreed that the hypertrophied heart is to
34 NORTH CAROLINA MEDICAL SOCIETY
be looked upon as the result of a persistently high blood pressure. The fund-
amental idea enunciated by Gull and Sutton that back of the disease we call
chronic interstitial nephritis is a disease of small blood vessels and that the
lesions of the kidney are secondary manifestations, was abandoned for a
time but already in 1913 the work of Jores, Aschoff and Gaskell showed a
return to this idea.
Harvey and Klotz experimentally maintained a state of high pressure con-
tinuously in young animals by placing them in an inverted position for three
minutes over a period of 120 days and at the end of that time were able to
demonstrate the production of marked sclerotic changes in the blood ves-
sels. Again arterio-sclerotic lesions have been produced by repeated injec-
tions of such blood pressure raising substances as adrenalin, nicotin, barium
chlorid, etc. Other evidence for the priority of the hypertension to the
vascular sclerosis is seen in the fact emphasized by Sir Clifford Albutt that
atheroma of vessels is especially common at those points in the arteries in
which pressures are greatest, such as at bifurcations, and at narrow points
and at dilatations. A number of autopses are on record of high pressure
cases in which vascular sclerosis was not found, and it is a commonplace ob-
servation now-a-days, that many cases of sclerosis of the large arteries show
no elevation of blood pressure.
The relationship of certain types of glomerular and diffuse nephritis to
hypertension is perhaps more problematical as to which is primary in point
of time. There are certain evidences which we cannot fail to take into con-
sideration as tending to show a probable primary character of the hyperten-
sion. Thus all experimental attempts to bring about a persistent hyperten-
sion by direct injury to the kidney by removing large portions of the renal
parenchyma or by ligating the renal vessels have been unsuccessful, and also
that extensive destruction of the kidneys as by chronic infections and amy-
loid disease causing severe functional impairment of the kidneys do not lead
to hypertension. Renal extracts have not been shown to exert a continuous
pressure influence.
Given these facts then which represent the result of experiment and in-
ductive analysis the question arises can we still look on high blood pressure
as a compensatory phenomenon. It is not too much to say that if we con-
sistently held to the view that an elevation of blood pressure represented in
all its phases, systolic, diastolic and pulse pressure a conservative and com-
pensatory reaction for the maintenance of efficient function in one or an-
other organ, that we would make no efforts toward its reduction and give
no advice which would tend toward such a result. It is to be realized, how-
ever, that heart and vascular system have reciprocal relations and functions
to perform in the maintenance of efficient circulation of the blood and it is
possible that a compensatory mechanism is in play in some phases of high
pressure, the generally prevailing view being that cardiac hypertrophy and
increased systolic pressure are compensatory to increased peripheral resist-
ance as measured by the diastolic pressure.
So far, then, as research and study have led us, it is recognized today that
a state of high blood pressure which is permanent represents the first stage
of the disease which we may call after Janeway Primary Hypertensive Car-
dio-Vascular Disease or after Barker Cardio-Vascular Renal Disease.
PRACTICE OF MEDICINE 35
What then is the cause of high blood pressure? The answer is, of course,
that ^ye do not know. Certain general etiological factors have been under
suspicion, of course, as various pre-existing diseases. Warfield in 1917 stud-
ied 500 cases of arterial sclerosis with relation to the infectious diseases as
possible causes. He arrived at the conclusion that the general infections
played no part in the etiology of this condition.
Syphilis: Janeway in 1916 studying the possible relation of syphilis to
high blood pressure found a lower incidence of positive Wassermann's in
320 cases of hypertension than in all the cases of his series as a whole. Stoll
in 1915 concluded from the study by Wassermann's and luetin tests of a
fairly large percentage of cases that syphilis was the underlying factor in a
much larger percentage of cases than had previously been realized. The
luetin test was shortly afterward discredited however. Walker and Haller
in 1916 found less than 7% of positive reactions in chronic nephritis with
hypertension. Levison of Toledo in 1916 studying 18 cases of syphilis with
high blood pressure concluded that anti-syphilitic treatment cannot be ex-
pected to reduce hypertension in syphilitics who have also high blood pres-
sure though admitting that occasional reductions may take place.
Focal Infections: It is most important to correct all foci of chronic in-
fection in any disease. However, Elliott of Chicago, studying 68 cases of
high pressure with relation to focal infections, was unable to find any reason
to think that hypertensive vascular disease bore any relation to focal in-
fections. In 1917 Strickler of Atlanta reported one case of hypertension
cured by the removal of dental focal infections, and stated that he could
quote others due to Rigg's Disease and sinusitis. Apart from this one case
I have failed to find in the literature of the past ten years any cures of hy-
pertension ascribed to the clearing up of focal infection. No reference is
made here to the cure of nephritis in general by eradication of focal infec-
tions, for brilliant results were reported last year by Hunt of New York in
this connection.
Foods and Intestinal Intoxication as a cause are indeed under suspicion
and must continue to be. There is much circumstantial evidence to im-
plicate the intestinal tract but nothing very definite has been worked out be-
yond the fact that various substances of a pressor nature. have been isolated
from the intestinal current, as well as substances which have a damaging
eflFect on the kidney substance.
CLASSIFICATION
As one studies cases of high pressure carefully it is impossible to avoid the
tendency to classify them into various groups on a clinical basis. If we
await the autopsy in order to group them on an anatomical basis we lose an
invaluable guide in treatment. Dr. Cabot has said that treatment must
often be on a symptomatic basis.
Classifications have been advanced by Stone, Stengel, Barker and others.
From the clinical point of view as a guide to treatment and prognosis the
classification of Warfield has served us best in the differentiation of cases.
By this classification. Group 1 is the so-called chronic interstitial nephritis,
characterized by marked impairment of renal function and the predominance
of renal symptoms, polyuria, nycturia, low sp. gr., constant traces of al-
36 NORTH CAROLINA MEDICAL SOCIETY
bumen in urine, renal type of low grade edema. The phthalein output is
low, there is retention of urea and creatinin. Both systolic and diastolic pre-
sure are high (200; 120-140) and there may be a high leucocyte count. The
heart is enlarged to the left. At autopsy the type shows small red coarsely
granular kidneys with thin cortex and adherent capsule. Death in this
group is by uremia most often or by cardiac failure.
Group 2 include cases often found by accident. They are large fleshy ro-
bust apparently healthy people who with years of freedom from ailments of
■any kind suddenly appear in the physician's office. On examination and
questioning renal symptoms are absent. There is neither edema, polyuria
nor nycturia. The urine is normal and renal function is normal or nearly
so. Blood urea and creatintin are only slightly increased if at all. There
is marked cardiac hypertrophy. The blood pressure is very high. There is
high grade left ventricular hypertrophy and slight enlargement and dilata-
tion of the aorta. At autopsy the kidneys are not contracted, the cortex is
not decreased in size and the capsule strips readily. Microscopically the
principal change is a diffuse fibrosis of the arterioles with only slight changes
in the epithelium and glomeruli. Death is usually by apoplexy or perhaps
by cardiac decompensation.
Group 3 is found typically in well nourished individuals who are over-
weight or who have been overweight at some previous time of their life.
They present no renal symptoms. There is no polyuria and no nycturia
and the urine is nearly normal. Phthalein output is only slightly reduced,
and blood urea and creatintin are only slightly elevated. The blood pressure
picture is characterized by a high systolic pressure, and by a nearly normal
diastolic with a pulse pressure higher than that seen in either of the other
two groups, equal to or greater than the diastolic pressure. The heart is
much enlarged. This type in our experience is particularly often found in
women over fifty years of age, and their symptoms are essentially cardiac
with palpitation, and a tendency to anginoid pains. Often gaseous disten-
tion of the abdomen is one of their most chronic and annoying symptoms.
Death in this group is by gradual cardiac decompensation. At autopsy
there is high grade hypertrophy of the heart and the kidneys are said to be
enlarged with cortex of normal thickness. I say said to be enlarged, for I
have not had the opportunity of obtaining an autopsy in this type of case,
though it is a common clinical type to find. Microscopically the chief
changes are again found in the arterioles with but minor changes in the
epithelium and glomeruli.
These three groups will, I think be readily recognized by every clinician.
Is it necessary that they should be differentiated and how may they be diff-
erentiated? Above all it is necessary that high blood pressure cases should
be properly studied and grouped. Because we have no specific remedies
these unfortunate people are too often passed over with but cursory exami-
nations and with the brief hasty advice to cut out all meats from theiir diet
and not to exert themselves.
Janeway said in 1915 "To tell every patient with albuminuria or hyper-
tension to stop eating red meat, or worse still to go on a milk diet is evidence
either of ignorance or inexcusable laziness. To group properly cases of
hypertension requires first of all a careful study of renal function by obser-
PRACTICE OF MEDICINE 37
vation of daily water intake and water output, phthalein tests, estimations
of blood urea and creatinin and chlorides and a careful study of blood pres-
sure reactions and cardiac function. With increasing experience one may
often forecast from the symptoms and pressure reactions the group into
which a case will fall when carefully studied later. However, such a meth-
od of classification without a study of renal function is mere guess work.
It is nothing less than a moral duty to work out thoroughly these cases
and to give them appropriate advice and treatment. In cases of group 1,
diet will be vitally important, requiring the reduction to a reasonable degree
of their protein intake, a diet yielding a basic ash, and purin free. In group
2 the treatment will aim above all to avert a cerebral calamity while in
group 3 every care and attention must be given to avert cardiac decomf>en-
sation. The wise pilot is he who focuses his attention on the particular
rock toward which the ship is drifting and not those which lie far from the
course of the ship.
MECHANISM OF CONVULSIVE MOVEMENTS OF THE OR-
BICULARIES AND FACE, AND THE MANNER
OF THEIR REMOVAL.
Dr. Tom A. Williams^ Washington^ D. C.
Corres. Member Neurological Society of Paris, etc.
We are all familiar with convulsive movement of the face due to chorea.
It is physical, due to cerebral infiltration by organismal products. Another
type of convulsive movement of the face, of physical origin, due to encephal-
itic irritation, has been seen by some of us in cases of encephalitic during
the recent epidemic. The mechanism of that is also simple. Another type
of convulsive movement of the face of physical origin is that of orbicular
spasm, in which the eyelid twitches. That, again, is due to irritation of the
facial nucleus, of encephalitic origin. The management of a disorder of
that kind is laid down in the textbooks. There exists quite a different type
of convulsive movement of the face.
For instance, a woman of fifty was sent to me some years ago by Dr.
HefFron, of Syracuse, New York, because of a grimacing of the face. At
the snme time this woman's head. turned toward the right. She had seen
an eminent neurologist in New York, and he recommended that the sterno-
cleidomafi-oid muscle be sectioned. This done, I need not say that no bene-
fit was obtained. She was later sent to me and the discovery was made that
this movement had nothing to do with any physical disorder, but was a
movement directed toward an end, which was brought about not from a
disturbance of the sterno cleidomastoid muscle, but the whole mechanism of
turning the head and pulling the face to the right was involved. What was
the stimulus? It was found to be a psychological one. It was found that
the woman had a niece with whom she had been in the habit of walking,
the niece always walking to the left of the aunt. The niece was about to be
married. So determined was the aunt not to consent to this that she could
not help turning her head away from the niece, so painful was the idea of
her prospective marriage to one of a class of foreigners who had always
caused misery to their wives in the manv instances she knew.
38 NORTH CAROLINA MEDICAL SOCIETY
Another case of like character was a young woman in Washington whose
neck turned because behind her sat a woman with whom she was always try-
ing to make up a quarrel.
Another case of the kind occurred this Spring, a lady from South Caroli-
na, was sent to me by an ophthalmologist because she could not open her eyes
and had not been able to do so for two years. She could not go on the
street, could not conduct her household affairs, could not read, and could
scarcely write. Also she had a high blood pressure and looked like an old
woman. Altho I recognized the psychogenetic nature of the condition, I
was unwilling to undertake treatment because of her condition and age.
However, examination showed that there was no serious arteriosclerosis nor
kidney disease. She was a much more intelligent woman mentally than she
looked. First we found out the cause of this effect. It had come on during
the war, when she had great responsibility and anxietj^ Why responsibili-
ty and anxiety caused the convulsions of the face which caused her eyes to
close so tightly was that when a young girl she had formed the habit of
closing her eyes whenever any painful sight or even thought would occur.
It seemed more bearable then. When this occurred she tried to abstract
herself, which she did by not seeing what was before her, so she closed her
eyes. It was a manner of withdrawal. This had become a habit but had
never given any trouble until the great distresses of the war. Then the
eyes remained closed. At the same time her vision began to age, so she
went to an ophthalmologist for the fitting of glasses. But the constant clos-
ing of the eyes produced an effort to keep them open, which led to spasmodic
movements. So she was sent to another ophthalmologist, who told her that
the glasses she had were wrong and gave her some others. Naturally, no
good was done, because the trouble was not in the vision but in the mind.
So she became worse and worse. Explanation and re-education enabled her
to go home in a month vastly improved. She was able to read and write, and
go out alone.
Another, a man from Wilmington, tried to keep his face straight by
chewing his lips. He was a sea captain and had great responsibilit}' during
the war. Finally he got so that he could not open his eyes at all. He too
was much improved.
The last case is that of a Washington man who, during my absence in
France, was sent to a famous clinic. There he was seen by ophthalmologist,
neurologist, psychiatrist, internist, serologist, and all sorts of examinations
were made, nothing objective being found. He could not open his eyes.
This man when I saw him was in a stage of phobia in reference to his eyes.
He feared that he was going to lose his sight. He was so terrorized by his
visits to different doctors and hospitals that he could not get his eyes out of
his head. The phobia on which the whole thing really depended had been
reinforced by injudicious management, which was not based on a knowledge
of the cause. The genesis was interpreted as follows: The conjunctiva had
become irritated by considerable driving along dusty roads in an automobile
in the glare of the summer sun ; in conjunction with the short sleep and the
conviviality entailed by late hours. The protection of the eye-balls by lower-
ing the lids was the consequence. In the manner of the tics, this physiolo-
gical response eventually became a psychological habit. This habit the pa-
PRACTICE OF MEDICINE JV
tient might have shaken off as he had done previously with other tics; but
in consequence of repeated medical opinions expressed during six weeks be-
fore him by distinguished men in a famous hospital there was added to the
habit, the phobia of the inability to open the eyes and the fear of loss of
sight, and, with it, earning capacity.
These cases all illustrate the fact that convulsive movements ot this kind
depend upon mechanisms of psychological nature. They originate in an un-
easiness. That may be of physical origin. There may be some general con-
dition toxic like Bright's Disease, high blood pressure or endocrine, as in
dysthyrodia and dyspituitarism.
For example, a physician's daughter, aged eleven years, was brought be-
cause of loss of interest in her lessons, of which she had previously been very
fond, grimacing of the face and eyes in spite of all correction, equivocation
and fibbing in attempts to evade her duties, and greediness amounting to
gluttony. She had always been a stout child, but had become enormous dur-
ing the preceding year or so.
Exploration of a possible psychological cause for this change of behavior
was fruitless ; so psychomotor exercises were begun for the facial tics. The
only effect of these w^as to arouse the patient's resentment; they were not
perserved with. Some time after, great somnolence manifested itself, the
child becoming very lethargic and even dropping ofi to sleep in the middle of
a task or at the table for a few moments. This directed attention to the
function of the pituitary gland so this was immediately explored by the
levulose test. As this showed great increase of the tolerance of the system
to large amounts of sugar, it was decided that the pituitary gland was func-
tioning insufficiently; great increase of weight, torpor, psychic inadequacy
and its attendant changes in behavior being symptoms of lack of pituitary
secretion. Feeding with increased doses of pituitary gland was at once be-
gun. The child recovered completely in a few months, and after the onset
of puberty was able to dispense with the pituitary gland ; and now, seven
years late>r, is active and comparatively thin.
Whether physiological or psychological the patient is made uneasy, and
so he changes position to get relief. On the other hand the urge may be
purely psychological, due to worry, anxiety, etc. It is the business of the
physician to find out the cause of the movement so that he can overcome it.
The first step is to find out exactly with what you are dealing. The second
is to teach the patient to perform movements in a controlled fashion.
Some ten years ago I succeeded in healing some cases of the kind, but also
failed on several. I only discovered in the last few years that we failed by
pushing exercise too rigidly. The greatest discretion is needed to prevent
further constraint being developed by the patient. Much patience is needed.
When that is done, I think that nearly all of these cases should get rid of
their convulsive movements. But that must depend also upon the re-edu-
cation of the patient's attitude toward the difficulty, because the condition
is fundamentally psychological.
40 NORTH CAROLINA MEDICAL SOCIETY
ANAEMIA, WITH THE REPORT OF TWO CASES, ONE SEC-
ONDARY AND THE OTHER PRIMARY.
Dr. K. C. Moore, Wilson.
, This paper has principally to deal with the report of two cases of anae-
mia. I am reporting the first case, a case of secondary anaemia for two
reasons, first that it taught me some very valuable lessons in making a diag-
nosis, and second on account of its being a very interesting case.
Mrs. W., age 22, married, came to me on account of general weakness,
numbness in the extremities, shortness of breath, palpitation and occasion-
ally pain around the heart, loss of weight, sleeplessness and complained of
being very nervous. She had been going backward for about two years.
Her loss of weight was very gradual, had only lost about twenty pounds
during the two years. She had been married for two years to present hus-
band. First husband died after living with her only a few months. First
husband was supposed to have died of tuberculosis. She has had no children
by either husband but has had two mis-carriages during her second married
life and is now five months pregnant. She has suffered with a great deal of
nausea during this entire pregnancy. She has had two abdominal operations
during the past three years. The first about three years ago for appendici-
tis, the second about twelve months ago for a large right cystic ovary. She
had no complications with either operation, wounds healed nicely.
Examination: The patient is very pale, the conjunctiva and mucous
membranes are very pale, her teeth are good, tonsils are of normal size and
appearance, there is no glandular enlargement in the neck, the chest is thin,
ribs rather prominent, breasts are very small, showing an atrophy rather
than an enlargement. On inspection, palpation, auscultation and percus-
sion the lungs are normal. The heart is of normal size. There is a low
systolic murmur heard at the base and is not transmitted. With this excep-
tion the hearts sounds are normal. Rate is rather fast, 90. Abdominal ex-
amination is negative with the exception of an enlarged uterus reaching to
the umbilcus. Patella and eye reflexes are normal.
Blood pressure at this time was 110, urine normal, both chemically and
microscopically. Blood: Hemoglobin 65, RBC 3,400,000, WBC 6,700.
Diff. Poly 59 large lymph small lymph 24 and eisin 2. The red blood cells
were fairly constant as to size, they showed a distinct diminution of color-
ing matter. There were no nucleated reds, very slight poikilocytosis. This
patient was put on tonics and digestants with no improvement. I question-
ed the husband very closely as to venereal diseases. He admitted having had
Gonorrhoea, but flatly denied ever having syphilis. I knew the people well,
they were of the better class of people, and although I suspicioned syphilis
1 could not make myself believe it strong enough to have a Wassermann
made. This is where I made my mistake. The patient went from bad to
worse as the pregnancy advanced. She began to show albumin and casts in
the urine, the blood pressure slowly began to rise and the blood condition be-
came worse. Finally, I suggested consultation and the consultant made a
Wassermann which showed four plus. She was then put on mercury in-
unctions daily and fifteen drops of the syrup of iodine of iron was given
after each meal. She was put to bed and kept there on practically a protein
PRACTICE OF MEDICINE 41
iree diet. Her condition improved wonderfully. Labor pains started up
just a little after the eighth month, and she had a normal delivery of a dead
baby. The inunctions were continued for two or three weeks and then
small doses of neo-salvarsan were given weekly. After three doses the
Wassermann was negative and has remained negative until the present
time. She has given birth to a normal child who is now two years old. The
kidney condition has entirely cleared up, her blood is normal, and she has
gained about twenty-five pounds.
There was never at any time anything suggestive of syphilis about this
case with the exception of the miscarriages. A wassermann of the husband
was negative. She has never had any eruption of any character. This case
has taught the lesson that you can never be sure of the absense of syphilis in
any one until you have thoroughly investigated. I have made it a rule since
this case came under my observation to take a Wassermann of every case I
examined, and never be sure of any thing until I had looked for myself.
The second case I wish to report is a case of primary anaemia.
Wm. W., male, 61, married, wholesale merchant and farmer. P'irst ex-
amination Aug. 27, 1917. At this time patient came to me complaining of
indigestion with a severe diarrhoea. (A year or two previously I had ex-
amined this patient for life insurance and turned him down on account of a
Chronic Bright's Disease, at this time he had a blood pressure of about
180). Until he began to suffer from the indigestion and diarrhoea he had
always been in good health. There was nothing else of any importance in
the history at this time. Examination : Patient is well nourished, weight,
169, muscles are well developed, tongue is a little red, especially at the tip,
teeth and gums are in good condition, there is no glandular enlargement in
the neck. Examination of the chest shows the lungs to be normal. The
heart is slightly enlarged, apex extending to left and below the nipple line.
Its sounds are normal. The abdomen is some what distended and slightly
tympanitic; on palpation there are no tender areas. The liver and spleen
do not show any enlargement. Patellar and pupil reflexes are normal.
Stomach analysis : There is no free hydrochloric acid, the total acids are
much diminished, lactic acid negative, Microscop. examination negative.
Blood: Hem. 80% red blood cells 3,336,000, whites 7,800, Differ. Poly-
mor. 60, small lymph. 22, large lymph, 16, and eisin, 2. There is a very
large variation in the size of the red cells, some of them being two or three
times the size of a normal red cell and others being a great deal smaller.
There is a marked poikilocytosis — Wassermann negative.
Urine: Slight trace of albumin, sugar negative, acid, and a few small
hyalin casts. Blood pressure 135-90.
Stools are watery with a great deal of undigested food particles, repeated
examinations showed the absense of occult blood.
A diagnosis of Primary Anaemia was made and dilute hydrochloric acid,
arsenic in the form of Liq. Potass Arsenit. was prescribed. The diarrhoel
condition improved for the time being and the blood remained fairly station-
ary through the winter of 1917 and 1918. In the spring the diarrhoel con-
dition returned, and the anaemia began to become more marked. Sodium
cacodvlate was substituted for the Fowlers with no improvement. By June
42 NORTH CAROLINA MEDICAL SOCIETY
1918 the red count had gone as low as 2,500,000 and hemoglobin to about
fifty-five percent. At this time I advised transfusions. Not being willing
to trust myself with them, I advised him to go to Dr. Barker of Baltimore.
I carried him there in July and his blood count on arrival, about three
weeks after my last count was Reds 1,792,000 hemoglobin 50%. He was
given a transfusion of 2500 cc. of blood which raised his count to red
blood cells 3,000,000 and hemoglobin 75%. He remained in Baltimore
about six weeks receiving two other transfusions, and returned home about
the middle of August with a count red blood cells 4,800,000 and hemo-
globin 100%. He was greatly improved in every respect. Was troubled
with diarrhoea very little, weighed 178, and looked after his business dur-
ing practically all of the fall and winter. In March, 1919, he reported to
me again, saying that he had not been feeling so well during the past few
weeks. At this time diarrhoea was very severe, and blood examination
showed as follows* Red blood cells 3,000,000 hemoglobin 70%. I ad-
vised him to take further transfusions before he got down so low. He be-
came rather despondent and said he would let me know. I did not see very
much of him any more until June, when I was called to his home. At this
time I found him very weak, the color of a ],emon, suffering a great deal
with dizziness and numbness in the extremities. Blood exam, as follows:
Red blood cells 750,000 and hemoglobin less than 30%^. I told him that if
he didn't have some transfusions and as soon as possible that he would die.
We sent him to Baltimore again. On this trip he received seven trans-
fusions in eight weeks time and returned to Wilson with a count of red
blood cells 3,100,000, hemoglobin 80%o. He did not feel as well from these
transfusions as after the first. Remained very weak and on Sept. 3rd, had
dropped back to 2,022,000. I again advised transfusions and on Sept. 14th
transfused 500 cc blood, Sept. 21st, 500 cc, Sept. 28th, 650 cc, Oct. 5, 1200
cc, 12th 1000 cc, 19th 1000 cc, Nov. 16th, 350 cc, and on Nov. 30th,
1200 cc. This was the last transfusion given and the following are counts
made since the beginning of the last series of transfusions: Sept. 22, 2,-
352,000, Sept 27. 2,104,000, Oct. 6, 2,920,000, Oct. 18, 3,472,000, Oct.
27, 3,048,000, Dec. 10, 4,236,000, Jan. 27, 1920, 3,368,000, Feb. 20,
3,992,000 and April 12, 2,280,000. During this past winter he has been
fairlv comfortable, has been up and about most of the time, has suffered
very little from the diarrhoeal condition. He has maintained his weight
pretty well, weighs now 168. For the past two or three weeks he has been
losing ground very rapidly and is very much in the need of transfusions.
I intended to give him another transfusion the past week, but have not
been able to get a sufficient amount of blood worked up, so he will be trans-
fused again the latter part of this week. During the intervals between the
transfusions he has been getting arsenic in various forms. I believe this has
helped to hold his blood up, but I have never been able to influence it ai
the least when it was low with anything except blood.
This case has been kept alive for nearly two years with blood. Other
remedies were tried very extensively on him without results. The cost of
his living these two years has been rather expensive, but I am sure that he
feels that he has gotten his moneys worth, because he is still ready and will-
ing to take the transfusions, and does not hesitate to pay for the blood.
PRACTICE OF MEDICINE 43
The method used in this case was the citrate method. This is very sim-
ple and there is practically no danger if the bloods are properly matched.
To each 250 cc blood, nine grains of chemically pure sodium citrate dis-
solved in one ounce of normal salt solution, made with freshly distilled
water, is added and stirred constantly while the blood is being drawn. The
blood is drawn by inserting a thirteen to fifteen gage needle into the medium
basillic vein, the arm is corded above and the donor instructed to open and
shut the hand. I prefer to use the thirteen gage needle as there is less likeli-
hood of the needle becoming stopped up. It is also a very good idea to pin the
vein to the skin with a fine combric needle to prevent it from rolling about.
It is also easy to reinsert the needle when pinned, if from any reason, it
should slip out. It is best to draw the blood in the same room with the
recipient, and keep the vessel covered with a hot towel to keep it warm.
This very often prevents a chill. I think it is very important to keep the
blood warm. Where the blood has been transfused quickly and has not
been allowed to become chilled I have had practically no reactions.
The most important part of the technique in giving a transfusion is in
having the bloods properly matched. This is a very simple procedure and
any one can do it who knows how to use a microscope. The method I have
used is as follows: One drop of each the donors and recipients blood is
added to about one cc of a one and one-half percent solution of sodium cit-
rate in normal salt solution, each blood of course, in a separate test tube.
This gives us the blood cells. Into a centrifuge tube about one cc of blood,
from the donor and recipient are put aside and allowed to coagulate. After
coagulation takes place the clot is removed and the serum is run for a few
minutes in the centrifuge to separate all the cells. A hanging drop is then
made of a drop of the donors serum with a drop of the recipients cells, and
one with a drop of the recipients serum with the cells of the donor. The
slides are looked at with a low power every four or five minutes and the
slides shaken to insure a thorough mixing. If the bloods match the cells in
each slide remain evenly distributed, if they do not match the cells in one
or both slides become clumped together. If agglutination does not take
place within thirty minutes the bloods match and are safe to use. There
are four blood groups, and if we have a known group 2 blood it is easy to
group any other blood by testing against this blood.
Transfusions are becoming more widely used every day, with an accurate
matching system the dangers have been reduced to a minimum. They are
not only indicated in the treatment of primary anaemia, but in the treat-
ment of any severe case of secondary anaemia after the exciting cause is re-
moved. They will save many lives in surgical patients who have suffered
from hemorrhage. A transfusion is an absolute specific for an oozing hem-
orrhage. A patient can hardly bleed to the point where transfusion will not
save, providing it is properly matched and given while there is still life:
In these cases the greatest source of failure is in not giving enough blood.
The bloods of brothers and sisters usually match, but this is not always
true. No case should be transfused without first doing an agglutination
test. The donor should be a healthy person, and a young person is alvi^ays
perferable to an elderly one. No person should be used as donor until a
Wassermann has been made and found to be negative.
44 NORTH CAROLINA MEDICAL SOCIETY
DISCUSSION OF DR. MOORE^S PAPER: ANEMIA.
Dr. R. a. McBrayer, Sanatorium: One thing that I would like to
ask the doctor is what kind of Hemolytic anaemia the man had ? Another
is whether he has ever employed the blood pressure apparatus in taking
blood from the vein or in putting blood or medicines into it. In doing this
I take the blood pressure, and after ascertaining the systolic, diastolic and
pulse pressures, divide the latter by three. Now substract this quotient
from the systolic reading. This gives the pressure, when applied, that will
allow the arterial blood to come thru the arm band and will at the same
time obstruct the venous return which means that you will get a permanent-
ly distended vein and the flow therefrom will be constant and under pres-
sure which adds much to the ease in which blood can be withdrawn from a
vein. Equal advantage is in intravenous injections for as soon as the needle
enters the vein (the blood which is under pressure) the blood begins to
flow into the syringe. Immediately an assistant opens the air valve on the
blood pressure apparatus and there is then in the vein an increased and more
rapid flow centrally which is very desirable in such work.
Dr. Moore^ closing the discussion: Dr. McBray^r's point about
the blood pressure is very important. I have never used the blood pressure
instrument, but have always been careful to see that the pulse is not cut off
when the arm is corded.
The case I mentioned was one of pernicious anemia.
ARTERIAL TENSION AND ITS CLINICAL
MANIFESTATIONS.
Dr. Charles H. Peete, Warrenton, N. C.
Ho7iored Presidentj and Gentlement of The Medical Society of The State
of North Caroli?ia :
In venturing to make a few remarks on Arterial Tension I recognize at
once that I am entering into a field of extreme extent, and one that has
been, and is being explored and investigated from every angle. And still
we are confronted with no problem of greater importance; and I am speak-
ing not to air any views or pet theories of my own, but to get the subject
under discussion in a simple way, and see what the genlemen of this great
State can advise in the way of prevention and treatment.
Arterial Tension, high or low, is really an abnormality of circulation;
it is a condition ; it has a cause ; it does not exist as an entitv with no be-
ginning. It has been found from time immemorial. But it is hti/ie/ found in
greater frequency as the years roll by. One cause of this may be that hav-
ing been awakened to the fact we look for it ; and we have greater diagnos-
tic facilities. But the fact remains that there is more arterial disturbance
than there has ever been. I take it that it is the pace of present-day life,
or living, a faster if not a fast, life, that is the chief cause of arterial abnor-
mality. The tension may be high, or it may be low. The high pressure
man struggles and hustles and keeps up with life; the low pressure man
cannot keep up with the pace, and like a toddling infant he stumbles and
falls as he tries to advance ; but the high pressure man has kept up with the
PRACTICE OF MEDICINE
45
pace until he gets exhausted, or nearly so, and then wearily falls into the
arms of the ever-ready medical friend and wonders why he is tired or feels
wrong. The queer point is that they never think their manner of life or
struggle causes their condition: — I do not here refer to the introspective
neurasthenic. Life now is a competition, a race. And one engaged therein
feels it, and the stimulation of it. The man who lives his life with an even
mind and an easy attitude of life is seldom bothered with arterial abnor-
mality. But he is a rare person indeed who does not permit the cares and
worries of life to disturb his equanimity of spirit. It is my opinion that this
mental attitude and lack of knowledge of the rules of proper living are the
chief causes of arterial abnormality as we see it nowadays. I tell you frank-
ly, gentlemen, it is appalling how little the average man knows how he
should live. I mean in regard to food, rest, sleep, work, recreation, and
mental activities. Mr. Business Man always asks how to run his automo-
bile, how to run his factory, studies minutely how to run his business ; but
he practically never asks or studies how to use the wonderful machine God
has given him so as to keep it in the best shape and repair. The knowledge
of the rules of right living, and their observance, is both the preventive and
treatment of our subject; and it is the key problem of it. But we get the
man when he is about down, or feels the wear; and we have an impaired
mechanism to make over, — a difficult job. We all know about the "type"
of man with arterial degeneration; we know that improper eating and
drinking is a great cause of it. Right here though, I want to say that it is
not always too much food; the correct preparation and the correct foods
are too seldom used, and faulty foods, limited number of foods, and faulty
cooking, will cause arterial degeneration just as quickly as other toxic causes
and do it more insidiously. There are the multitudes of toxins, syphilis,
and what not, that are responsible ; and there is no need to enumerate them,
if one could. Nor is it necessary to more than mention worry, business
pressure, lack of sleep, lack of recreation, — all these with improper eating,
improper foods, and the toxic causes are the reasons of this degeneration.
I do not believe that work per se is a cause ; but work and worry is a great
cause. We find the increased tension in any person, man or woman ; proba-
bly it is more frequent in men, but it is getting more prevalent with women.
Thinness or stoutness makes no difference. I believe one outstanding fea-
ture we all recognize is that increased pressure is an abnormality of advanc-
ing years, although often we can measure a man's age better by the sphygmo-
manometer than we can by the number of his birthdays. Nearly all show
vertigo; many have a heart so strong as to shake the whole body or head
when they are sitting quiet. There is the angina not only of the heart or
aorta, but of the leg, abdomen, or arms. And the feeling of oppression in
the chest, all sorts of digestive disorders, with weakness after eating by giv-
ing the heart more exertion. Often a woman cannot arrange her hair or
raise her arms. There is the tendency to fall in certain directions; the var-
ious paresthesias, and the hot and cold flushes as well as the inability to
keep warm or to get cool in hot weather. The kidney symptoms are too well
known to need comment. Often tinnitus is the first symptom that brings
the patient to the doctor, and like the vertigo, it is one that is apt to re-
main. I believe the fat high-tension man suffers more than the thin ; he
can't get about so well, nor can he arrange his position for comfort as well.
46 NORTH CAROLINA MEDICAL SOCIETY
Under treatment he often gets thin, but it is unwise to try to reduce to
thinness a man who has always been stout, he is very apt to be made ex-
hausted. In regard to the low pressure subject we are apt to find him a
thin person, phlegmatic, with little energy. He is apt to have a hereditary
condition, for his parents or their family are apt to have shown the same
characteristics. He is prone to have abdominal ptoses of all sorts, and piles;
as well as digestive disorders and melancholic mental views ; he is apt to be
a pessimist. He fatigues easily and does not like exertion ; also he passes
into a neurasthenic state very quickly. I have never been able to find any
definite ascertainable cause for low blood pressure, and I have found it in
the young adult as well as in the old. It would seem almost to be a part
of the individual or his make-up. And from observation I have been forced
to come to the conclusion that in spite of his ptoses, dyspepsias, etc., he is apt
to be long lived. One thing is that he never has energy enough to over-
work himself; and his heart beats so slow it gives itself plenty of time to
rest itself. And I have never found any treatment, and I have given them
all known cardiants, tonics, baths, massages, diets, ets., that would alleviate.
I do not advise office life however, but ask them to go to the farm if pos-
sible.
I shall not speak of medicine for the hig'h-tension man ; we all have tried
the whole Pharmacopeia and have made no definite cure. We have to try
and relieve the symptoms, and we should. But the best plan is to put the
patient to some likable occupation with moderate bodily work, and get him
into a mental attitude that will prevent worry, and instruct him how to
live properly with food, sleep, rest, recreation. I do not believe we should
take proper work in right amounts from the patient; it leaves his n^ind too
mudi unoccupied ; but at the same time he must learn that it is just as im-
portant to rest with relaxation as it is to work. One type of hypertension
I fear has been injured by too much solicitation on our part is the big man
who has what seems to be essential hypertension ; in other words the pres-
sure of 170 to 180 seems to be really his measure. I have seen such men go
for years with no urinary or other damage. But I do think such cases ought
to be properly warned, directed, and observed, but not overly coddled. I
should like to get an expression from this assembly what it thinks in regard
to the use of tobacco in hypertension. I have never been able to decide the
question to my satisfaction. We see tobacco users live very old. I cannot
say I think it causes hypertension ; but I do think the continued use of to-
bacco once hypertension is established does not tend to reduce the condition.
TOXIC ARTHRALGIA. '
Dr. O. Edwin, Finch, Apex
By this condition I mean. Painful Joints, with but slight swelling, and
usually an associated myositis, which is more commonly known as "rheu-
matism." In some cases a mild infection of the joint may be associated.
The prime etiological factor being toxins, produced directly or indirectly
by bacteria at some distant focus or foci. In this paper I do not intend
to discuss the various locations in which foci of infection may be found,
capable of producing toxic arthralgia.
PRACTICE OF MEDICINE 47
Toxic arthralgia is found more frequently involving the shoulder, sacro-
iliac, hip, knee, cervical spine, wrist and ankle joints. Rarely involving the
lesser joints — toes and fingers. It is also rarely symmetrical. If more than
one joint is involved, the hip of one side and shoulder of the other or vice
versa.
The onset is usually insfdious. Pain the chief symptom which is but rare-
ly definitely localized to the joint, usually radiating in the line of muscle
and nerve distributions. For instance, if the hip is involved, the pain us-
ually radiates in the course of sciatic nerve. On exercise the condition is
made worse. Pulse and temperature are but rarely affected.
The areas in which foci of infection may be found, in order of their im-
portance are — 1st, teeth, 2nd tonsils, 3rd gastro intestinal tract — a key to
which may be expressed by three "T's", teeth, tonsils and 'testines. By the
tonsils, I mean the naso pharynx.
The teeth : Dr. Mayo recently said, "The next great step in preventive
medicine will come from the dentist, — will they take it?" Six years have
elapsed since Billings published the important fact that septic foci, even
when small, are a source of infedtion when transmitted by the blood stream.
Oral sepsis has come into prominence only recently in connection with what
is called focal infection. The particular pathological condition found in
the mouth, of which we are especially concerned are :
(A) Pyorrhea or supperative gingivitis.
(B.) Alveolar abscesses.
(C.) Infected pulps.
(D.) Apical abscesses.
(E.) Discharging sinuses and
(F.) Granulomas .
The most important factor about these conditions are that for years they
drain their insidious toxins into the alimentary canal, lymph and blood
channels without giving the slighest symptom that would cause the patient
or physician to suspect their existence. Even should they produce symp-
toms, when 3'ou first mention such a condition as the source of trouble, be-
ing in the teeth, the patient will declare you are insane for he believes every
tooth in his head to be as sound as a silver dollar. Those lesions that are
more or less enclosed are the most dangerous, for here the toxin is drained
into the circulation and sooner or later, alone or in conjunction with some
predisposing factor, they will break down the resistance of the patient and
produce toxic arthralgia and other systemic ills too numerous to mention.
I have in mind a white male, age 45, who came into my office on crutches.
He complained of severe pains located in the shoulder and hip joints. Un-
der the care of another physician the salicylates had been used with no de-
gree of improvement. On examination of his teeth I found pyorrhoea in-
volving two lower molars and three lower incisors, with free pus easily ex-
pressed from around these teeth. Without prescribing, he was referred to
a dentist who extracted the five teeth, and rendered surgical treatment. In
two weeks time the patient had obtained complete function. This case is
not the typical, to the contrary his condition was atypical. It is in the
typical cases that we find those obscure infections of the teeth, particularly
48 NORTH CAROLINA MEDICAL SOCIETY
blind abscesses and pulpless teeth ; for they require our most diligent work.
In fact the diagnosis of oral sepsis is not a one man's job, particularly for
the physician. It is necessary for the physician, dentist and xray man to
work together. The dentist taking the clinical and xray findings into con-
sideration, is alone qualified to make the final diagnosis. I make it a rule
to but rarely advise a wide and complete extraction of all teeth without
first invoking the aid of the xray man. So often we are prone to make a
superficial examination of the teeth and refer the patient to a dentist, with
instructions to leave not a tooth. Almost as often we fail to get results
with these cases, for more than one reason, but one particular, is because we
have not made a diagnosis with the aid of the xray man and a dental sur-
geon. Taking for granted that our diagnosis is correct we fail to obtain
results because there may still exist pus pockets in the gums or alveolar
processes, which mere extraction of the teeth has failed to drain. The den-
tist should lightly cureette the alveolar pockets and break up any shell that
may be protecting the pus pockets. Even though extraction has been com-
plete in some cases and no results obtained, you should have an xray picture
made of the alveolar processes for the presence of pus pockets. It is my
honest conviction that a part of the dental profession are responsible for a
large percentage of oral sepsis by the insane practice of destroying nerve and
blood supply, i. e., removing the pulp, treating root canals and allowing
pulpless teeth to remain. Drs. Rosenow, Billings and Hartzell contend
that pulpless teeth are a menace to the human system, and should, without
exception, be removed. A pulpless tooth is a devitalized tooth, (Dr. A. D.
Black reports that 47% of devitalized teeth have alveolar abscesses; others
report as high as 80%.) When the pulp is removed from a tooth its dentin
becomes dead dentin in the same sense that bone in which the bone corpus-"
cles have been killed is necrosed bone. How many of you would like to
have the surgeon leave dead bone in your osteomyelitic femur or tibia as
the case might be? Recently, I inquired of a dentist why it was that he
continued to practice such dentistry. He replied: "Should I insist on re-
moving those teeth the patient would discharge my services and seek a den-
tist who would give "treatments" and encourage the patient to retain his
so-called sound teeth." So long as such an attitude as this exists in the den-
tal profession just so long will we continue to have septic oral conditions
and innumerable systemic ailments traceable to such foci.
It is not the removal of a sound tooth we desire, therefore, a word of
precaution is not amiss. Teeth should never be removed unless the indi-
cations are clear. We have passed the area of ovariectomy, appendectomy,
with our patients, be careful what we promise them, save serviceable
teeth whenever possible. It is not the counsel of the radical, nor the ultra-
conservative dentist that we desire, but a happy-medium-fellow who
is willing to launch out in mid-stream and by the grace of God and
the aid of the Xray do that which he feels and knows to be good den-
tal surgery. Having found such a dentist sustain him in his ef¥orts to
educate the public in oral hygiene.
Tonsils or Nasopharynx: It is to the faucial tonsils that we owe an
apology for so many of our sins of misdiagnosis. I am not referring,
necessarily, to those tonsils that are enlarged and obstructive ; it is the
PRACTICE OF MEDICINE 49
infected tonsils; whether it be enlarged, obstructiv^e or embedded. I
know of no better way to emphasize this than by relating, in a super-
ficial manner, a case record — Miss S., white, aged 19, came to me
complaining of pains in her left shoulder joint, and the joints of her
right Icnee. She had been the rounds of general practitioner, electro-
therapeutist, stomach specialist, etc. Examination was negative with
the exception of her tonsils. She had a pair of embedded and infected
tonsils. From the cryptic areas free pus could be easily expressed. She
was referred to a throat man who removed her tonsils under ether. In
three months time from the date of her tonsillectomy, she was free from
all pains. Had good digestion, appetite and color. During this time
she gained thirty-one pounds. Previous to her operation she stated that
she could not digest or retain but very little food, for this reason she
consulted the stomach man, — -I cannot understand how the somach spec-
cialist could pass a stomach tube down her throat and not see (or smell)
that he was slipping his tube past the primary into the secondary condi-
tion. He finally informed her to go home and not return for further
treatments, as he could not benefit her condition. I could not help but
admire his frankness after he had given her two months stomach tube
treatment with its associated scientific fractional test. Dr. Thos. McCrae
says "More of us make our mistakes by not looking and feeling — not that
we do not know." In our effort to determine if the tonsils are at fault
it is very necessary that a close and pains-taking examination be made.
Merely using a tongue depressor and making a superficial inspection is
not an examination. It is necessary to use a probe guarded with cot-
ton and search out the crypts, and other obscure areas of the tonsils.
Have the patient make digital pressure at the angle of the jaws, which
will push the tonsils nearer mid-line, then grasp the anterior pillar with
a tonsil retractor, make pressure with a blunt instrument over the body
of the tonsil. In many instances pus pockets will be identified that
would otherwise be unobserved. Get the idea out of your mind that the
wall bracket lamp and head mirror are intended only for the ear, nose
and throat specialist. The physician who fails to equip his office with
modern fixtures will not be able to locate these finer points in diagnosis.
Very often tonsils are infected secondarily from the teeth. I do not
think that tonsils should be removed without first attending to the teeth.
Dr. Rosenow declares that the lymphatics of the mouth and jaws drain
into the tonsils. Some of the infections of the tonsils improve, or may
entirely disappear following extraction of infected teeth.
Accessory Sinuses: Infection here is more common following influenza.
It is not the acute sinusitis that is most likely to produce arthralgia; to the
contrary, it is the chronic variety that produces a continuous stream of
poisons that is most likely to produce arthralgia. Evidence of such infec-
tion is usually found in a patient sufiEering with so-called "Catarrh of the
head," usually a profuse yellowish, fetid, nasal discharge; more commonly
it is unilateral. He will complain of a bad taste in his mouth, appearing
irregularly during the day. Pain is an indefinite symptom but if present
it is usually located over the eyes and in the temporal region. As a means
of diagnosis the xray and trans-illumination are the most reliable.
In conjunction with nasopharynx the chronically infected middle ear,
50 NORTH CAROLINA MEDICAL SOCIETY
and mastoid are not to be forgotten. I believe that a long continued at-
track of otitis media is responsible for more chronic joint pains than is gen-
erally credited to this area.
Gastro Intestinal Tract: The stomach as a primary focus for the ab-
sorption of toxins producing arthralgia is rarely at fault. In fact the
stomach is but rarely ever the primary seat of any systemic affection. We
recognize gastroptosis of some importance on account of the slowness in
which food passes, allowing chemical and bacteriological changes to occur —
thereby serving as a medium for the production of toxins, which, if ab-
sorbed may in this manner produce a toxic arthralgia.
More commonly do we find the gall sac the seat of trouble. In order to
have elaboration of toxins it is not necessary for gall stones nor an acute
cholecystitis to be present, altho a history of having had such a condition
is a predisposing factor. It is the chronically infected gall bladder that is
more commonly the greatest factor here. The most prominent symptom
here is a slight intermittent pain, made worse by deep palpation at the angle
of the ribs ; with heavy percussion an area of soreness may be elicited at the
angle of the right scapula. History of slight indigestion, eructation of gas
after meals, frequent toxic headaches. The symptoms referable to the gall
sac are in proportion to the pathological changes. The point I wish to em-
phasize is the absence of the more prominent signs and symptoms of gall
bladder trouble, which may lead us to ignore this region as a possible focus
of infection. Infection of the gall bladder may gain entrance thru the blood
stream or by way of the ducts from the intestines. Inflammation of the ducts
produces stagnation and stagnation predisposes to infection. Such a gall
bladder may contain a thick mucoid secretion ; — a veritable hot bed for the
progressive multiplication of bacteria and their toxins. Xray examination
here will be practically negative.
The large and small intestines as factors in producing arthralgia may be
summarized as chronic intestinal stasis. The conditions producing such a
stasis are numerous, a few of which I will mention: Chronic appendicitis,
adhesions, kinks, enteroptosis fecal impaction, foreign bodies, volvulous,
mtussuseption herri;e's, cicatricial stricture, tumors, paralysis, etc. What-
ever the factor in producing stasis, the essential truth to bear in mind is the
production of toxins by bacteria and chemical changes of food. The stasis
permits more absorption of these poisons by the cfrculation, thereby pro-
ducing constitutional symptoms, particularly arthralgia. The large intes-
tines play such an important part in the absorption of poisons that Metch-
nikofif. Lane and others would regard it as a useless and dangerous en-
cumberance and would take it out and throw it away.
The appendix I will endeavor to consider alone on account of the pre-
valence of chronic appendicitis. In such a chronic infection we find an area
that is directly or indirectly responsible for toxic arthralgia. I feel that we
have passed the age when it was not safe, nor wise, for a patient to come to
us with a pain located in the right iliac fossa. Therefore, we are to adopt
a conservative idea of appendicial inflammation. A chronically inflammed
appendix is a focal infection absolutely as capable of producing arthralgia
as an apical abscess or pussy tonsils. The patients so afiEected are not, but
in few rare instances, aware of any trouble located in this region. They
PRACTICE OF MEDICINE 51
may in some cases complain of pain in the region of the right sacro iliac
articulation or in the right flank or perhaps the right hip joint. I do not
mean by this that every patient who has a pain in these regions is afifected
with chronic appendicitis, but a careful examination and painstaking his-
tory for such a condition may help to confirm or eliminate this focus. In
chronid appendicitis, dyspepsia may so dominate the clinical picture as to
lead us to believe the case to be one of gastric disease. There may or may
not be tenderness in the region of the appendix, altho, occasionally in those
recurrent attacks, tenderness may be found at McBurney's point.
, In attempting a diagnosis of any gastro-intestinal lesion producing toxic
arthralgia, the greatest aid will be a thorough clinical examination sup-
plemented by a thorough x-ray analysis.
In making your diagnosis as to cause of toxic arthralgia, do not stop
when you have found one focus, for there may be many foci, which are to
be remedied before your patient will realize relief. Search diligently for
those areas of focal infection. Let your motto be similar to that of the
Royal Northwest Mounted Police, "In attempting to find your man, let
your trail lead you to the uttermost parts of the earth, but find your man."
So it should be with us — even tho the symptoms should lead you to the
uttermost parts of the human anatomy — find your focus or foci of infec-
tion. The treatment of toxic arthralgia may be summarized with three
words, — "Remove the cause."
Dr. J. M. TempletoNj Cary : I want in the first place to express my
gratification that so many young men are reading papers at this meeting
and I wish to discuss them not so much in the hope of shedding more light
on the subject, but rather to encourage young men in such efforts that they
may profit by my mistake not waiting till they are too old to write well. I
would be especially glad to say something on the paper of my friend, Dr.
McBrayer's son, but I must admit I never heard of the test of which it is
the subject until this good hour ; also that of my friend Leinbach, but I
know too little about "hypertension" to do so. My friend Dr. Findh has
just read an excellent paper on an up to date subject. It presents two
points that impress me: First, the futility of treating symptoms; second,
the importance of looking back of the effect to find the cause.
When I graduated some 40 years ago I knew that a pain in the knee was
sometimes a symptom of disease of the hip-joint and I was often on the
"anxious seat" lest I prescribe chloroform liniment applied to the knee for
a case of morbus coxarious.
The first important reflex, if I may call it such, of the character with
which Dr. Finch's paper deals, that I recall was eye strain, which was so
ably championed by Dr. Ambrose L. Ranney. That was years and years
ago and I guess I was impressed by it because Dr. Ranney was one of the
faculty at the University of New York City when I was a student there.
He made the mistake most pioneers in such things made in carrying them to
extremes, professing to cure everything from "corns to consumption," by
correcting eye-strain, still he succeeded and got where he could keep his
private yacht.
Next we had the era that attributed everything, especially everything
feminine, to the condition of the organs of generation, celiotomies and ab-
52 NORTH CAROLINA MEDICAL SOCIETY
dominal section became the fashion with a holocaust of sacrificed wombs,
tubes and ovaries. Next, I think, taking them in chronological order, we
began to attribute a multitude of diseases to the appendix and gall bladder
and these organs were cut out by thousands. After a time we found that
these operations would not cure everything, and sanity and system and
common sense led us to discriminate when and when not to operate.
Now we turn to the tonsils and teeth and there's a tendency to go to
extremes in getting rid of them, and bye and bye, we'll know when and
when not to remove them. Then it will be something else, possibly follow-
ing the hints in Dr. McNider's paper. When we find albumen in the urine
we'll treat the liver as the offending organ. It's strange to me that for
thousands of years we never traced these diseases back to these causes. I
expect it would have astounded Old Hippocrates if he'd been told rheuma-
tism could be cured by extracting a tooth or tonsil. Yet we may have some
equally wonderful things ahead of us. Do you know I never treated a case
of Osteo myeltitis in a baldheaded man in my life ; will we cure it some day
by pulling out a tuft of hair ?
The cardinal symptoms of meningitis are connected with the feet ; Kernig
and Babinski's signs and will we cure it some day by pulling out toe nails?
SYMPTOMATOLOGY OF TYPHOID FEVER
Dr. p. R. Hardee, Stem.
Since promising to write a paper on typhoid fever, and not having done
so, I feel that I am due the stenographer an apology. I feel that I am also
due the Society an apology for promising to write a paper when I knew
full well that I could write nothing that would be legible.
In taking up this subject, which goes back into tradition, I know that
you are not going to expect anything new or startling from one who can
not write anything, legible. The thing, gentlemen, that we are most in
need of in the symptomatology of typhoid fever is some cardinal symptom
which, in the early stages of the disease, will point the way and help to
make the diagnosis easy. Unfortunately, however, the symptomatology of
typhoid fever is somewhat as it is in tuberculosis — there is no cardinal symp-
tom by which we can recognize the disease in its early stages — and often
before it is recognized it makes great inroads and many lives are thereby
lost.
Now, it is true that we have some tests by which we can say with some
degree of positiveness that our patient has typhoid fever, provided those tests
are positive, but none of these tests are supposed to be positive under about
six to eight days. For instance, the Widal reaction is not supposed to be
positive before the eighth day of the disease, and the test that I have found
to be of more benefit to me than any other is the Russo test. I think that
you will find it positive earlier than by any other test.
In treating this disease, and studying the symptomatology, it may be that
I am a little bit presumptuous, but I believe that I have found that symp-,
tom which we, as general practitioners, are so much in need of in the early
stage of the disease. I have found what, to me, is a cardinal symptom. It
is a symptom that I have found present in a large majority of the cases on
PRACTICE OF MEDICINE 53
my first or second visit. It enables me to say with a good bit of certainty,
certainly on the second visit, that the patient has typhoid fever. It is this
symptom about which I am going to talk to you this afternoon. It was
first noticed by me on taking over a case of typhoid fever in the month of
September, 1917.
In taking over this patient, who was in about the fourth week of the
disease, in going over him in my examination I found the heart and lungs
normal, or as nearly normal as you would expect to find in a patient in the
fourth week of the disease. But when I placed the stethoscope in the upper
gastric region, well nigh under the ensiform cartilage, I detected a sound
that I had never before heard in that region. It was something that was
new to me, and I did not know what to make of it. The sound that I
heard was more like the sound produced in a loud murmur in mitral regur-
gitation than anything else to which I could compare it at the time. I went
back and put the stethoscope over the heart, but there was no mitral regur-
gitation. I should have said that this sound was synchronous with the pulse.
I knew that it was a heart sound. Instead of getting a pulsation at the end
of the ensiform cartilage, we got an explosion. It was much like the noise
of an aneurysm, but there was no tumor and no pulsation, I knew that it
could not be an aneurysm. So I left that patient confounded and non>
plussed, not knowing what could produce the sound in his stomach that I
heard. Two days later I saw some other patients that had gotten infected
from this source, and I listened for that particular noise and found it pres-
ent in each one at the first visit. There were six or eight cases from that
source of infection which I treated in the next few weeks, and every one
produced that same noise in the very early stages of the disease, except one.
I have had one patient since who was short and stout and in whom the dis-
ease ran a very light course, and I detected no abnormal sound in his abdo-
men in the whole course of the disease. He is the only one I have seen
since 1917 who has not had that symptom from the very beginning and alJ
along through the disease. After seeing six or eight of these patients and
finding this sound almost always present I began to think that I had found
a new symptom of typhoid fever.
I realized, gentlemen, at once that if this noise which I heard in the epi-
gastric region, well nigh under the ensiform cartilage, was a symptom of
typhoid fever, it is valuable as a symptom in proportion as it is absent in
other conditions. So I went to work and examined the abdomen of every
patient I saw for quite a while, with negative results. After a few months
of patient searching there came to my office one day a small, thin, anemic
woman. I judged from the contour of her abdomen that she had reached
the sixth month in pregnancy. In going over her abdomen to see if I could
find the old familiar sound, I did not hear it in the epigastrium, but when
I got down to the right siliac region I heard the sound. I at once recog-
nized that it was what writers call the uterine bruit of pregnancy. So I
argued that if this was called the uterine bruit of pregnancy, I would
christen the sound which I discovered the epigastric bruit of typhoid fever.
It seems that the pulsation comes to the end of the ensiform cartilage and
splits up into a bruit.
I continued these examinations on every patient I saw, and the succeeding
spring there came a young man to my office suffering with symptoms which
54 NORTH CAROLINA MEDICAL SOCIETY
I thought were produced by a peptic gastric ulcer. In going over him
I detected the same sound. My tentative diagnosis in this case was gastric
ulcer. Knowing the young man's disposition as I did, I knew that I could
not cure him at home, so I sent him to a hospital, where they verified the
diagnosis with the different tests and put him to bed and cured him. He
came back home, but the bruit remained there for quite a while after he
was cured of the ulcer. Still I continued. A few months later I w^as called,
one night to see a woman, and when I got there they told me that she had
been vomiting blood and that she had vomited until she fainted. From the
amount of blood on the floor, I did not doubt a word about her having
fainted. I made a tentative diagnosis in this case of gastric ulcer. That
night the hemorrhage had stopped. As soon as I could make a manual
examination I listened for that particular sound, and about four inches
from the end of the ensiform cartilage, to the left, I heard it. I believe you
vvill get this bruit in gastric ulcer. I hope the gastroligist will take up that
hint and follow it out.
Now, as to the time, I have told you that you will find this bruit in the
very earliest stages of typhoid fever. A young man came to my office one
evening suiiFering with what he called indigestion and dyspepsia, but I no-
ticed that he had an epigastric bruit, the old familiar sound I had so often
heard in typhoid fever. Two days later I received a message from his fa-
ther stating that the boy was no better and to come to see him. He ran
the usual course of typhoid fever for four weeks and had hemorrhages. I
believe that we have in that bruit a cardinal symptom of typhoid fever in
the early stages. It has never failed to be present in every case I have seen
since I first detected it, except one. The number, however, is not large.
As to the time, you will find that bruit present not only in the beginning,
but present all the way through. I remember the last patient whom I
treated. It was the most prominent symptom all the way. When I dis-
charged that patient, when he was told it was unnecessary to come again,
the bruit was just as loud as at any time during the disease. I thought I
would follow up that case and see how long it would follow a case of
typhoid fever, so I instructed the patient to report once a week for an ex-
amination. He reported promptly for eight weeks and the bruit was still
there. I saw that he was getting tired and was wondering why I continued
to examine him so often, so I told him t6 come again at the end of a month,
which was three months after his recovery from typhoid. The bruit was
just as prominent then as during the disease.
I do not think there is anything more. I hope that you gentlemen will
look for this thing, and I believe you will be interested in it. It will help
you to say with a good deal of certainty to the patient, on the second or
third visit that he has typhoid fever. The symptoms are so indefinite in
early typhoid, so unreliable, that it takes a good time to say whether it is
typhoid. This is the one reliable symptom that I have been able to find in
the early stage of the disease, and it stays there all the way through. 1 do
not know to what it is due. One doctor said that it might be due to anemia,
but I have treated cases of pernicious anemia and have not found it. 1
hope some scientific man will take up this matter and find out what pro-
duces this bruit.
PRACTICE OF MEDICINE 55
SOME FACTS. OLD AND NEW, CONCERNING THE HEART
AND THE PULSE
Dr. Hubert Benbury Haywood, Jr., Ralj^gh, N. C.
The advances in this branch of medicine in recent years have been so
marked and the changes of opinion so great that they strike one as being
almost revolutionary in character.
The polygraph and electro Cardiagraph have come into use and enabled
Clinicians of diagnose abscure conditions, as auricular fibrillation, heart
block, and other diseases of the myocardium and its valves.
However, Sir James MacKenzie, in a recent work states: "The em-
ployment of instruments of precision fosters the idea that medicine is be-
coming more scientific with the extension of their use, and there is a ten-
dency to rely more and more upon them, and to substitute them for the
senses of the physician. I have little hesitation in saying that this attitude
towards methods of examination which is dominant today is based on a
fallacy. So far from the clinical methods of examination by the unaided
senses being exhausted, they-have not been sufficiently cultivated, and the
substitution of mechanical methods for them shows a lack of understanding
of what clinical medicine means and how its study should be presented."
The classification of symptoms in dealing with a diseased heart will show
the functional efficiency of that organ. The symptoms revealed by a me-
chanical device cannot well do this, for they belong to the structural group.
The Stethoscope shows a heart murmur, and too often we put this down
as the whole story and write finis after the patient's name.
We do this in spite of the fact that the heart is in full compensation and
there is no evidence of disease of the myodardium. Why not study the
clinical symptoms and find the real potent condition ? Is the myocardium
diseased, or is there only a valvular condition present? May not the so-
called functional murmur heard over the heart, if it fits in with the clinical
symptoms, be indicative of disease of the myocardium and really be of more
importance as to prognosis at the time than a loud systolic murmur at the
mitral valve?
Valvular disease of the heart is with few exceptions easy of recognition.
Changes in the heart muscle are, on the other hand, often extremely diffi-
cult of recognition. Although the term "Heart disease" is in the hands of
many of the laity, and the profession also, associated with a valvular lesion,
it cannot be too strongly emphasized that the ability of the heart to carry
on its functions is dependent almost entirely on the condition of the Cardiac
muscle. The majority of valvular lesions are for a long time, and in many
instances, always of secondary importance.
So long as the heart muscle remains healthy, the heart subject to chronic
valvular disease is capable of performing its work as well as a normal heart.
When, however, the heart muscle becomes exhausted as the result of com-
pensation having reached its limit, or when the heart muscle becomes de-
generated as the result of disease, with or without valvular defects, the
most serious circulatory disturbance takes place.
56 NORTH CAROLINA MEDICAL SOCIETY
Degenerative changes of the heart muscle are too often over looked, al-
though the etiological factor should put us on our guard. Diphtheria is a
well recognized cause of acute degenerative changes in the muscle, and may
end fatally unless prompt recognition is made. Too often a condition that
is real and vital is passed up and diagnosed as "weak heart."
The structural changes which take place may be: Physiological or path-
ological hypertrophy.
Dilation of one or more of the chambers.
Degenerative changes of the muscle, which may be acute or chronic.
Unusual conditions such as syphilitic gummata, abscess and aneurysm.
Two forms of hypertrophy are noted.
Simple hypertrophy without change in the size of the cavities of the
heart.
Hypertrophy plus dilation of the cavities.
Valvular disease is the commonest cause of hypertrophy. Chronic adhe-
sive pericarditis is another cause. Arteriosclerosis and chronic Nephritis
are the next commonest cause of hypertrophy. Excessive beer drinking is
a common cause. Tachycardia, as seen in Graves' disease, due to increased
cardiac action, is often noted as a cause.
The changes in a myocarditis which impair the structure and the func-
tion of the muscle may affect all ot only a portion of the heart muscle.
The severity of the lesion will therefore often depend upon its location
rather than its extent. For instance, a degenerative change may affect the
auriculo-ventricular bundle of His and lead to a complete or partial heart
block. With a few exceptions, an acute myocarditis occurs as a result of
some acute infectious process.
Among the acute infectious diseases noted as affecting the myocardium
are acute Rheumatic Fever, Diphtheria, and Influenza, as we have all
learned to our sorrow, when often the signs of Cardiac weakness do not
appear for some time after the disappearance of the disease.
Syphilis may cause an acute myocarditis during the acute stages of the
disease. Typhoid Fever often leaves the myocardium permanently damaged.
It too often happens that in our anxiety over the primary disease we lose
sight of the secondary condition. Often the symptoms are so slight as to
be readily overlooked. Usually they are restlessness or apathy, breathless-
ness on exertion, and a sense of constriction in the chest, and sometimes
anginoid pain. In the more serious cases there will be evidences of dilatation
of the heart, cyanosis, dyspnea, precordial and hepatic pain, vomiting and
edema.
Physical signs show:
The patient is rather pallid and either restless or apathetic. If dilatation
has occurred there may be cyanosis and more or less edema of the lower
extremities. If dilatation has occurred the apex is diffuse and displaced to
the left.
The pulse is usually feeble, with or without an increase in rate ; after
influenza a slow pulse may be encountered for weeks after an attack. The
blood pressure is usually low after an acute myocarditis.
PRACTICE OF MEDICINE 57
If dilatation has occurred there is an increase in the transverse diameter of
the heart. If myocardial weakness is at all marked the valvular sounds are
accentuated and short, and the first sound lacks the normal muscular
quality".
The second pulmonic is usually sharply accentuate; either the first or
the second sound may be reduplicated. If reduplication of the first sound
occurs it is one of the first intimations of a dilatation.
A functional murmur at the mitral area is heard often, and at the same
time a similar murmur may be heard at the tricuspid area.
The causes of chronic myocarditis are varied. The chronic lesion is in
nearly all instances a sequel of an acute process.
The change is usually insidious and gives no evidence if its presence until
serious muscular inefficiency develops. One of the commonest causes is
disturbances of the coronary circulation with consequent poor nutrition of
the cardiac muscle. The causes of the coronary sclerosis are the same as
those of arterio-sclerosis in the body elsewhere.
The final stage of valvular disease usually is muscular inefficiency due to
myocardial degeneration. This is caused by overwork and perversions in
cardiac metabolism.
Included in this group are those instances in which the heart has for a
long time beat at greatly increased rate, the most notable example of which
is seen in exopthalmic goitre.
The muscular inefficiency usually manifests itself in that part of the heart
Avhere the strain has been greatest. Thus in general arterio-sclerosis, aortic
insufficiency, and the hj'pertrophy due to excessive exercise, it is the left
ventricle which is subject to the greatest strain.
On the other hand, chronic pulmonary changes produce the greatest
change in the right ventricle.
The clinical picture is a varied one. Often sudden death may be the first
intimation that the disease exists. Cabot states that the condition was rec-
ognized correctly in 22 per cent, of cases, overlooked in 22 per cent., and
diagnosed when not present in 52 per cent.
The most pronounced symptom is that of cardiac insufficiency. Very
often the symptoms of cardiac weakness are overshadowed by some special
symptom complex, as Angina Pectoric, Stokes-Adams disease, or hyperten-
sion with or without nephritis. The first intimation of myocardial weak-
ness may be transient attacks of dizziness and faintness, and this is espe-
cially apt to occur in robust middle aged men with hardening of the arteries.
Breathlessness and a sense of oppression in the chest after some light but
unusual exertion are early symptoms. Pain is especially apt to occur if
the exertion follows a meal. The pain passes ofi with the eructation of
gas. The trouble is oftimes erroneously called dyspepsia. Slight swelling
of the feet and ankles may be an early manifestation.
Dyspnoea may be associated with these symptims. In other instances the
patient suffers from collapse in which he sweats and has a feeble but slow
pulse. In these individuals with fatty overgrowth of the heart asthmatic
attacks are common. Their puffing respiration is usually ascribed to obes-
ity, but it is more often an evidence of cardiac weakness. In some corpulent
58 NORTH CAROLINA MEDICAL SOCIETY
individuals the face has a dusky, congested appearance which is commonly-
ascribed to ruddy health, but which in reality is due to venous stasis result-
ing from faulty heart action.
Examination of the heart will show some increase in dullness to the left,
and intensely accentuated second aortic sound, and accentuation of and a
valvular quality to the first sound at the apex. A harsh systolic murmur
at the aortic area is a frequent finding.
Briefly, it may be stated that the etiology and symptomatology of chronic
degeneration of the myocardium and the blood vessels are often essentially
the same and the presence of one almost invariably implies the other. It is
interesting in this connection to note some of the irregularities affecting the
contractions of the myocardium as shown in the pulse. The chief forms nre.
Sinus arrythmia.
Premature contraction or extra systoles.
Heart Block.
Auricular Fibrillation or delerium Cardis.
Auricular Flutter.
Paroxysmal tachycardia.
Pulsus alterans..
As we know, the heart muscle is composed of two types of tissue, the
mature, which is purely muscular and responds to the impulses; the primi-
tive, or neuro-muscular, which originates and conveys the impulses.
The sino auricular node, or pacemaker, situated in the wall of the right
auricle near the opening of the superior vena cava, under normal conditions
gives rise to the impulses exciting the heart to action. Nerve impulses pro-
ceeding from this node are distributed throughout the auricle and to the
nodal tissue at the auriculo ventricular junction, from which tissues they
are carried to every part of the ventricles by the Bundle of His or its
branches.
Under certain conditions, either temporary or permanent, the tissues of
the heart may become hypersensitive and give rise to impulse formation
which is more rapid than the pacemaker. These impulses may arise in any
part of the heart tissue either auricular ventricular or nodal, and replace
the impulses from the peacemaker. From these facts it seems that irregu-
larities occur in at least three ways.
1. Alteration of impulse formation at the sinoauricular node, due to
altered vagal impulses.
2. Hypersensitiveness in some portion of the heart, giving rise to im-
pulses which replace those from the sino auricular node.
3. Some disturbance, either temporary or permanent, in the conducting
system, which so interferes with its function as to block or delay the trans-
mission of impulses, the severity and location of the disturbance determin-
ing the degree and effect of the block. From the first of these it will be
seen that the heart itself is not necessarily impaired, but is simply respond-
ing to influences that are changed either in rate or rhythm, and that this
change is due entirely to extra cardiac conditions and is dependent to a
large extent, if not entirely, on altered excitability' of the vagal center.
PRACTICE OF MEDICINE 59
In the second the trouble is in the heart muscle but is due to hyper-
sensitiveness, the result of nutritional changes which may be purely tempor-
ary in character and without pathological change in structure. The third
group is more likely to be due to permanent alteration in the tissue, but may
be seen in acute infections when the heart muscle is involved, and which will
entirely disappear with disappearance of the infection and restoration to
normal.
Sir James MacKenzie, in commenting on irregularities, says, "Although
so little has been said about irregularities by teachers and writers, the sub-
ject has been by no means ignored in practice. So ingrained has the belief
become that a heart to be normal must be regular that when an irregular
heart was met with it was looked upon with suspicion and many persons
with sound hearts have been rejected for life insurance because of the pres-
ence of an innocuous irregularity, while tens of thousands have had their
lives restricted and have been subjected to prolonged and useless treatment
for a condition that called for no treatment. On the other hand, cases
where the irregularity should have revealed the necessity for treatment
were never properly understood and so were never properly dealt with."
Tht great majority of irregularities are of two kinds, one which occurs
in youth rind one which occurs in adult life.
Proceeding on these lines, after I had collected over a thousand cases, I
sought for some definite basis of classification. With the assistance of the
jugular pulse 1 ^vas able to recognize different forms according to the
mechanism of their production. Two large groups, which included be-
tween them 90 per cent, of all cases, emerged distinctly. These two groups
differed. In one all of the chambers of the heart participated in the irregu-
larity, the contraction in each case being normal, while in the other, the
ventricle contracted prematurely while the auricle maintained its rhythm,
or both auricle and ventricle contracted prematurely, the irregularity which
is now called the ventricular and auricular extra systole.
I was now able to separate the two groups by a second method, namely,
the age incidence. I found that the former group occurred predominantly
in the young (the youthful type of irregularity) and the latter group oc-
curred predominantly in the latter decades of life (the adult type of irregu-
larity.)
Accepting MacKenzie's statements as based on experience with persons
believing themselves to have heart disease, we must believe that the majority
of the cases are not suffring from disease of the myocardium.
Sinus arrythmia. MacKenzie goes so far as to claim that this form of
arrythmia is an indication that the heart is not damaged. He looks upon
the presence of this irregularity as an evidence that the heart has escaped
damage when the rate is found below 70.
Lewis claims: "The commoner forms of cardiac irregularity due to the
sinus are of little prognostic value and are to be regarded as slight exaggera-
tion of a normal phenomenon, respiratory irregularity, or as evidences of a
mild or insignificant instability of tonic inhibitory nerve action."
If it is respiratory in type, the change in rate with the rise and fall in
respiration will be easily detected. If it is not established by these means
it may be detected as the breathing is deepened.
60 NORTH CAROLINA MEDICAL SOCIETY
There is no irregularity in the force of the pulse, the waves being equal
in volume and the irregularity disappears as the pulse rate accelerates. It
is almost confined to rates below 100 per minute, is more noticeable as the
pulse rate decreases in frequency, and usually disappears after exercise.
Extra Systoles. MacKenzie states: "Seeing that healthy men and
women may present this irregularity, it can be accepted that extra systoles
in themselves are not indications of disease or impairment of the heart's
efficiency. When there are signs of heart failure the prognosis should be
based upon the other symptoms present and not on the presence of extra
systoles. It may therefore be stated that when the extra systole is the only
abnormal sign the prognosis is good and when it is associated with other
signs the prognosis should be based on these other signs.
Another authority (Wiggens) states that premature contractions may
arise in a perfectly normal heart. More often they arise in hearts that are
abnormally irritable. It may be assumed in these cases that irritability ot
the heart is increased through toxins, internal secretion, caffein, nicotine,
etc., so that it reacts to the tiny normal ineffective stimuli that bombard it,
or that pathological disturbances of structure are actually present.
Their chief clinical value is that they attract attention to the cardiac
condition, which leads to a search for the presence or absence of other symp-
toms of cardiac impairment.
Lewis, on the other hand, states that premature contractions constitute
and bear witness to defects ; that there is mechanical imperfection and there
is the evidence of altered cardiac nutrition, and the more frequent the in-
terruptions the greater the degree of such defects. Premature beats, true
paroxysmal tachycardia, auricular flutter and fibrillation have a common
pathological basis : they are one and all the outcome of new impulse forma-
tion in the heart.
The prominent points in diagnosis may be mentioned. The beats missed
at the pulse are heard at the heart and occur in threes and fours with a pro-
longed pause following, the number of beats being determined by the force
of the extra systole.
If not sufficiently strong to open the aortic valves but three beats will be
heard, otherwise four will be noticed.
The pulsations between the extra systoles are regular in both rate and
rhythm. The premature contractions very rarely accompany rates of 120
and over. While they not infrequently disappear after exercise, they do
not always do so. Extra systoles usually increase in frequency as the pulse
rate becomes slower.
In this connection I was interested in writing to several of the leading
Life Insurance Companies of this country. Their figures are rather
startling.
Group 29. Irregular Pulse found on examination or at some time within
ten years of the date of application. That group was made up of nearly
2,800 lives and showed a general average mortality of 95 per cent., biit
with a tendency at the later ages of life to a higher mortality, ages 50 and
over showing 22 actual deaths and 19 expected.
The next group studied was made up of persons with an intermittenr
PRACTICE OF MEDICINE , 61
pulse found at the time of the examination or within ten years of that time.
The number of lives involved in the study was over 2,100. The mortality
at the earlier ages was small and showed a tendency to increase with ad-
vancing age.
A third group was made up of persons who showed a pulse rate between
90 and 100 on examination. The mortality in this group was 172 per
cent., and this high mortality rate was not confined to any age but extended
through the entire historj- of the group. There were over 6,200 lives in the
group.
Finally, a group made up of persons with a pulse rate of over 100 found
on examination or within ten years. There were 740 odd cases under ob-
servation. The mortality was high everywhere. The general experience-
was 205 per cent.
In conclusion: A pulse of 90 and over is abnormal. Irregular and in-
termittent pulse is of decidedly less significance at the earlier ages of life
than at the later ages.
There is a distinct relationship between the amount of disturbance of the
pulse and the extra mortality incident thereto.
Finally, a heart murmur does not tell the whole story as to the condition
of the heart.
DISCUSSION OF DR. HAYWOOd's PAPER
Dr. Hardee, P. R., Stem: I wish I were able to discuss that paper^ f?r
this is a subject in which I have been very much interested.
There is one part of the paper that puzzles me as much as anything with
which I am confronted in the practice of medicine, and that is diagnosing
the different lesions when the myocardium is affected. I can usually, in
valvular affections, tell with some degree of certainty what particular lesion
it is, but when there is myocardial degeneration, with irregular pulse and
vague symptoms, it troubles me as much to make a diagnosis as anything I
meet with. .
Dr. O. Edwin Finch, Apex: I was very much interested in the doctor's
statement as to slow pulse, because I feel that I have been responsible for
some men's not getting insurance on account of that. Feeling that it was
due to some organic lesion, I have stressed it, and probably that applicant
may have been entitled to insurance.
I would like to ask Dr. Haywood if he has any explanation for slow
pulse following influenza.
Dr. Hajrwood: The only explanation that I have seen that is reasonable
at all is that it is due to a myocarditis associated with the disease.
Dr. A. McNiel Blair, Southern Pines: Dr. Haywood has presented
facts on a subject of special interest to us all, as we all have hearts, and of
particular interest and benefit to some of us, w^ho have been endeavoring to
give this subject special study.
It is indeed a broad subject, and the subject material is difficult to handle
in one paper.
In reference to myocardial changes, the grouping of certain clinical find-
ings is essential for the proper determination as to the integrity of a heart
62 , NORTH CAROLINA MEDICAL SOCIETY
muscle. Occasionally one or more constant factors exist which should al-
ways suggest further investigation, lest in the consideration of a patient
with other ailments, the heart muscle status per se be overlooked, as we all
know myocardial changes are presented in unusual ways, and are variable
indeed.
To be sure one notes rather constantly in many of the so-called classical
cases, palpable arteries that feel thick and resisting, or tortuous and un-
even, like a string of beads, and it is safe to presume that the heart muscle
in this case is not sound.
Palpatation of the liver should not be neglected, as the physical signs of
hepatic congestion are not improperly secondary to more or less cardiac
inadequacy.
Auscultatorv percussion helps to confirm ordinary percussion, and should
be practised more frequently.
The disparity noted between the first and second heart sounds has often
been the first factor in calling my attention to an abnormal heart muscle,
especially in a patient who presents strong, usually regular pulse, with no
Cardiac impulse, apparently normal heart dullness, clear heart tones without
murmur, and often radial arteries that are not stif¥, along with negative
urinary findings. The real nature of the case would have been overlooked
had it not been for this one sign ; accentuation of the second, with weaken-
ing of the first sounds.
The blood pressure findings, along with the study of the pulse rate, taken
not only in the recumbent position, but also sitting and standing, have been
helpful in determining the heart muscle strength. So also the Cardio-
radiogram or the fluoroscopic picture permits of outlining the heart and
large trunk vessel, revealing the approximate extent of dilatation, as well as
any other outside factor that may play a part in the disturbed mechanism
of the heart per se, as for example, in certain forms of pleural adhesions.
Dr. Haj'wood touching the subject of fibrillations, with associated heart
muscle changes, brings to mind a case of auricular fibrillation, where heart
muscle degeneration was not evidenced immediately, but was delayed some
little time, between two or three months. The one symptom predominating
during that period of apparent compensation was the extreme rapidity of
the pulse. Then there followed, in the advent of a cold, the degenerative
heart muscle changes in an aggravated form, with partial heart block, with
associated pericardial and pleural transudate.
I wish to express my personal appreciation to Dr. Haywood for present-
ing his able paper to the section.
REMARKS BY DR. HAYWOOD
A letter to an authority on the heart as to auricular fibrillation and heart
block brought this reply:
"So far as I know, a definite diagnosis of auricular fibrillation can only
be made with the cardiograph. It may be inferred in a case where the pulse
after reasonable exercise remains persistently irregular while the rate is
above 120 — and by pulse I mean the pulsation of the heart, not the radial
pulse.
PRACTICE OF MEDICINE 63
"Heart block can only be determined with the polygraph, but may be
suspected when beats are definitely dropped or when the apex beat as deter-
mined by the stethoscope does not coincide with the pulsations of the jugu-
lar bulb. A good plan is to put a small black piece of sticking plaster over
the jugular bulb to make any pulsations there more obvious."
Dr. J. T. J. Battle, Greensboro: Dr. Haywood spoke of how to test the
myocardium. That question used to bother me considerably, until I met
Dr. Lankford, of San Antonio. He gave me a very simple experiment to
go through with, which I have found quite satisfactory in every case. That
is. get the patient quiet, so that the systolic blood pressure will not be af-
fected by exercise or excitement. Take his blood pressure, both diastolic
and systolic. Exercise him equal to walking up two flights of steps, with
the arm band still on his arm but deflated. Then, thirty seconds after he
is seated, take the pressure again. If the heart is normal the systolic pressure
will have gone up from 15 to 25 millimeters, while the diastolic pressure
has remained stationary. It will return to normal within one to three
minutes. If there is a weak myocardium, it is slow in coming back to
normal. If there is a very weak myocardium, it does not respond to the
exercise and the systolic does not go up. If the systolic falls you have an
exceedingly weak myocardium. If the diastolic pressure rises and the sys-
tolic falls you have a man in a very dangerous condition. If you try that
you will find it exceedingly satisfactory. Of course, you must deflate the
c\\fi after each reading.
A REVIEW OF THE RECENT WORK ON AMCEBIC
DYSENTERY
WiLLi.AM Allan, Charlotte, N. C.
During the period of tlie war considerable advance has been made m
our knowledge of several of the factors of the amoebic infection problem,
particularly by our British allies. In their campaigns in the Eastern Med-
-iterranean area they were promptly confronted with serious casualty rates
from dysentery, and as the Gallipoli dysentery was reported as largely
amoebic by early observers, they met this situation by intensively training a
number of protozoologists and concentrating their chronic dysenteries in
special hospitals.
This war work has increased materially the definite statistical data ot
the incidence of amoebic infections among different races and in different
parts of the world. In examining about 31,000 British troops returned
from the Near East, the majority if whom had had dysentery^ or other
bowel disorders, 9.8% were found infected with Entamoeba histolytica:
(1). Of nearly 7,000 troops and civilians without any history of bowel
trouble, examined in the Eastern Mediterranean area, or invalided from
that region, 10.5% were found infected. In 5,000 persons with a record
of intestinal disorders examined in France and England, mostly troops from
the Western Front, 8.9% were found infected, while in 3,761 individuals
without bowel troubles, 5.8% were infected. Kofoid found 10.8% ot
1,200 American soldiers returning from France infected. The great ma-
jority of these individuals received a single examination, which Dobell has
shown brings to light less than one-half of histolytica infections, so that the
64 NORTH CAROLINA MEDICAl SOCIETY
figures given above are something less than half the true incidence of this
protozoal infection. Such a brief summary may give some idea of the
magnitude of the problem; of the approximately 50,000 persons examined,
both in Western Europe and the Near East, both healthy and dysenteric,
between 13% and 25% were infected with Entamoba histolytica.
Medical men have been handicapped by a lack of zoological knowledge
of the intestinal amcebae but have had to go blundering ahead because of
the slowness of trained protozoologists to lead the way out of this wider-
ness. Schaudinn in 1903 adopted the placing of the intestinal amoebae in
a new genus, Entamoebse, by Cassigrandi and Barbagallo, and emphasized
anew the distinction between pathogenic and non-pathogenic species. Dur-
ing the next ten years many new species were described by many observers,
the Entamoeba tetragena of Viereck being the most important. Walker's
(2) work in Manila in 1911 finally led to the abandonment of Schaudinn's
erroneous description of Entamoeba histolytica and to the boiling down of
the Entamoebas of man into two species, Entamoeba histolytica, pathogenic,
and Entamoeba coli, non-pathogenic. As the former has 4-nucleated cysts
and the latter 8-nucleated cysts, all seemed plain sailing for the easy difiFer-
entiating of species. But in 1917 Wenyon and O'Connor (3) described a
non-pathogenic Entamoeba of man, with 4-nucleated cysts, calling it En-
tamoeba nana. Their work has been accepted, confirmed and extended by
other British workers, and by our own protozoologist, Kofoid, who has
shown (4) that this new species is fairly common. Dobell (5) in his re-
cent excellent monograph on the zoological status of the amoebae living in
man has created a new genus for this amoeba, Endolimax, calling the organ-
ism Endolimax nana. So that we now have to deal with and differentiate
three species of parasitic amoebas, namely. Entamoeba histolytica, patho-
genic, with 4-nucleated cysts. Entamoeba coli, non-pathogenic, with 8- nu-
cleated cysts, and Endolimax nana, non-pathogenic, with 4-nucleated cysts.
The earlier work on differentiating the intestinal amoebae consisted largely
in staining active forms and then interpreting the amount and arrangement
of the nuclear chromatin. Needless to say this could never become a
popular method. Due to the work of Walker in 1911 (2) and of Mathis
in 1913 (6) and of many others, we have been led to turn from the study
of trophozoites to the study of cysts. This has been rendered very much
easier by the introduction of iodine, or such iodine stains as Donaldson's
(7), with which the specimen of stool is rubbed up in order to differentiate
the cysts. Iodine makes cysts much more readily recognizable and brings
out the nuclei sharply.
Dysenteries unsuccessfully treated become convalescent carriers, dis-
charging cysts in their stools intermittently for an indefinite length of time.
Besides these, there are many s(3-called healthy carriers, who present neither
past history nor clinical evidence of dysentery. When possible these cyst
carriers should be given the same course of treatment that acute or chronic
cases of dysentery receive, for besides being a source of infection to others,
some will eventually develop dysentery, and some liver abscesses.
Since Roger's introduction of the use of emetine in 1912, one advance in
the treatment of this infection has been made, namely; the introduction of
emetine bismuthous iodide. This preparation was first suggested by Dumez,
PRACTICE OF MEDICINE 65
A. G. (8) in Manila in 1915. A year later the British began using it and
seem to have demonstrated its value. Emetine bismuthous iodide, contain-
ing about 29% emetine, is given by mouth in salol or keratin coated tablets,
one grain two or three times a day. It may be used alone or combined with
emetine injections; at present there is a tendency to use emetine injections
for 10 to 12 days followed by two to three grains of the double iodide for
12 days in acute cases, and to give 12 to 14 day courses of the iodine alone
in treating carriers. Lillie and Shephard (9) cleared up 62 out of 104
carriers with 12 day courses of 3 grains of Emetine bismuth iodide alone.
Jepps and Meakins (10) cleared up 20 out of 24 carriers, and McKinnon
cleared up 70 out of 131 carriers. Savage and Young cured 14 out of 17
carriers and 8 out of 16 acute cases, with the iodine alone, 2 to 3 grs. for 12
days. Gunn and Savage (11) using emetine injections for 12 days, fol-
lowed by emetine bismuthous iodid for 14 days, treated 120 acute cases;
82 were discharged as cured, 46 after being kept under observation for
more than 30 days, 36 for less than 30 days; 38 of their acute cases re-
lapsed. They treated 190 carriers in the same way; 171 were discharged
as cured, 106 after more than 30 days, 65 after less than 30 days, 29 of
their carriers relapsed. Turner and Taylor (12) in 366 carriers had 67
to clear up without treatment; 215 were cleared of cysts with emetine bis-
muthous iodid, and '84 failed to clear up.
• These results from British military hospitals seem very encouraging, but
their men could be held for observation for only four or five weeks. In
spite of Dobell's findings that 90% of relapses in treated carriers takes
place within three weeks (13), McAdam has shown that many so-called
carriers relapse later on, and Walker long ago found the incubation period
of experimental Entamoebic infection running as high as 90 days.^ In civil
life, it would be better to follow cases for a year before pronouncing a cure.
In the few acute cases the writer has had the opportunity of treating during
the past year, emetine bismuthous iodid has cleared out the cysts, temporar-
ily at least, after emetine injections had transformed the dysenteric into the
carrier state. This new therapeutic agent will doubtless prove very useful,
but an estimate of its exact value must await a much more prolonged obser-
vation of its effects.
. The most important addition to our knowledge of the treatment of
amoebic dysentery has been presented by Dale and Dobell (14) who under-
tuok to work out carefully the strength of emetine solutions which would
be lethal to Entamoebas in dysenteric stools. They found that when em-
etine in solution was applied directly to the Entamoebae, it was not particu-
larly toxic, while it is a well known fact that emetine injections in human
amoebic dysentery have a specific amoebacidal efEect even in very small
doses. They also found that injections of emetine had absolutely no effect
on clinical amoebic dysentery in the cat. Therefore, as emetine seems to be
without efEect both directly and through the medium of the cat, but is very
effeotive through the medium of man, it is pointed out that the specific
action in clinical human Entamoebic Dysentery must be because of its action
on the host and not on the parasite.
56 NORTH CAROLINA MEDICAL SOCIETY
REFERENCES
( 1 ) The figures in this paragraph were obtained by tabulating the re-
ports of
Archibald, R. G., Hadfield, G., Logan, W. and Campbell, W. 1916. J. R. A.
M. C. XXVI-6-695.
Arkwright, J. A., York, W., Pi-iestly, O. H., Gilmore, W. 1916. Brit. Med.
J. p. 683, May 13th.
Aubert, P. 1917, Bull. Soc. Path. Exotique, Vol. X, No. 7, p. 611.
Barratt, J. O. W. 1916. Brit. Med. J., Nov. 4th ,p. 617.
Bayliss, A. A. 1919. Lancet, Jan. 11th, p. 54.
Bayma, T. 1916. Ann. Paulis. Med. e. Cirurg, 7-5-97.
Boney, T. K., Grossman, L. G., Benlanger, C. L. 1918. J. R. A. M. C.,
XXX-4-409.
Christie, W. L. 1915. Brit. Med., J. July 17, page 89.
Cowan, J. M., Miller, H. 1918. J. R. A. M. C, XXI, Nos. 3 and 4.
Cragg, F. W. 1917. Ind. J. Med. Research 5-2-301.
Cutler, D. W., Williamson, R. 1919. J. R. A. M. C. XXXIII, No. 3-252.
Dobell, C. 1917. Special Report Series, No. 4, Med. Research Com.
Dobell, C, Gettings, H. S., Jepps, M. W., Stephens, J. B. 1918. Special
Report S. No. 15.
Dobell, C. 1916. Brit. Med. Journal, Nov. 4th.
Fantham, H. B. > 1916. Lancet, June 10th, p. 1165.
Ficker, M. 1915. Ann. Paulist. Med. et Cururg. 5-2-335.
Findley, G. M. 1917. Lancet, May 19th, page 755.
Fischer, W. 1918. China Med. Journal XXXII, No. 1, page 13.
Fischer, W. 1915. Dent. Arch. f. Klin Med., 118-2-129.
Flu, P. C. 1918. Abs in Trop. Dis. Bull, Vol. 12, No. 5, page 287.
Gunn, J. W. C, Savage, R. E. 1919. J. R. A. M. C. XXXIII, 5, 418.
Hall, I. W., Adam, D. C, Savage, R. E. 1916. Brit. Med. Journal, Aug. 5,
p. 174.
Hughs, T. A. 1919. Ind. Med. Gazette 54-4-139.
Jepps, M. W., Meakins, J. C. 1917. J. R. A. M. C, XXIX, 6, page 704.
Jepps, M. W. 1916. Brit. Med. Journal, Nov. 4th, page 616.
Kofoid, C. A., Komhauser, S. I., Smeezy, Olive. 1919. Arch, Int. Med.
24-1-35.
Leb@uf, A., Brown P. 1916. Bull et Mem. Soc. Med. des Hopit. de Paris
31-27-1602.
McAdam, W, 1918. Lancet, Jan. 5th, page 15.
McKinnon, D. L. 1918. Lancet, Sept. 21st, p. 386.
Martin, C. J., Kellaway, Williams, F. E. 1918. J. A. R. M. C. XXX, No. 1,
page 101.
Matthews, J. R., Smith A. M. 1919. Ann. Trop. Med. & Parasital. 13-1-88.
Rangel, Prestana B. 1917. Ann. Paulist. Med. e Cururg. 8-5-101.
Ravaut, P., Krolunitski, G. 1916. Presse Medicale, Vol. 24, No.37, page 289.
Rocke, W. 1917. Lancet, Feb. 24th, page 297.
Sanford, A. H. 1916. Journal A. M. A. 67-26-1923.
Savage, R. E., Young, J, R. 1917'. J. R. A. M. C. XXIX; No. 3.
Tribondeau, Fichet. 1916. Bull Acad. Med. 75-11-317.
Turner, O. P. & Taylor, N. 1919. J. R. A. M. C. XXXIII-3-245.
PRACTICE OF MEDICINE 67
Wenyon & O'Connor. 1917. "Human Intestinal Protozoa in the Near East."
Wenyon, C. M. 1916. Journal R. A. M. C, 26-4-445.
Woodcock, H. M. 1917. J. R. A. M. C. XXIX, No. 3, page 290.
Woodcock, H. M. 1919. J. R. A. M. C. XXXH, No. 3, 231.
(2) Walker, E. L. 1911. Phil. Journal Sc. VI, page 259.
(3) Wenyon, C. M. & O'Connor, F. W. 1917. "Human Intestinal Protozoa
in the Near East."
(4) Kofoid, C. A., Komhauser, S. I. & Plate, J. F. 1919. J. A. M. A. 72,
page 1721.
(5) Dobell, C. 1919. "The Amoebae Living in Man."
<6) Mathis, C. 1913. Bull d. d. Soc. Chirurge de I'Indo. Chine, June 8,
Sept. 14th, Nov. 9th and April 19th, 1914.
(7) Donaldson, R. 1917. Lancet, ii, page 571.
(8) Du Mez, A. G. 1915. Phil. Jour. Sc. X, Sec. B, page 73. .
(9) Lillie, D. G. & Shepheard, S. 1917. J. R. A. M. C. XXIX-6-700.
(19) Jepps, M. W. & Meakins, J. C. 1917. Brit. Med. Journal, Nov. 17th,
p. 645.
(11) Gunn, J. W. C. & Savage, R. E. 1919. J. R. A. M. C. XXXIII,
No. 5, 418.
(12) Turner, O. P. & Taylor, N. 1919. J. R. A. M. C. XXXIII, 3, 245.
(13) Dobell, C. 1917. Special Report Series No. 4, page 51.
(14) Dale, H. W. & Dobell, C. 1917. Jour. Pharm. & Exp. Thor. X-6-399.
Dr. T, E. Anderson, Statesville : I would like to ask Dr. Allen vs^hat
are the comparative results of giving Emetine hypodermically and by mouth ?
Dr. Allan, closing discussion : Emetine has been given by mouth in
keratin coated tablets.* However, this irritates the stomach and is not a
successful method. Several years ago, I reported the use of Alcresta ipecac
in ten cases, four of which responded to treatment. This is about half
as good as the results by hypodermic injection. At present bismuthous
emetine iodid by mouth is being tried extensively. Any method that
avoids the necessity of making the chronic cases stop work daily and go
to the doctor for a hypodermic, would be very welcome.
Dr. Taylor has asked what to do with cases that do not respond to ipicac.
I find that a course of emetine cures permanently about 40% ; about the
same number are temporarily relieved of symptoms, but will relapse, and
about 20% do not respond to ipecac. This latter class can be made com-
fortable by colon irrigations of saline, or magnesium sulfate, or silver ni-
trate, and the course of the disease tends toward recovery after a period of
years.
THE MODERN THERAPEUTIC VALUE OF DIGITALIS.
Dr. Joseph A. Speed, Durham, N. C.
The use of Digitalis in disease is chiefly based on its powers in giving
rest and tone to the heart and as a diuretic by virtue of its ability to im-
prove the general circulation. It is distinctly a cardiac stimulant, and upon
the circulatory system finds its greatest field of usefulness. It does not stim-
ulate the renal epithelium or have any effect on the renal structures. In
moderate and effective amounts it increases the pulse force, slows the pulse
Ob NORTH CAROLINA MEDICAL SOCIETY
and increases the pulse wave. The increased pulse force is said to be due
to a stimulating influence which the drug has on the muscular fibres of the
heart itself. And some observers have claimed the drug permits the heart
to do two and one-half times the amount of its normal work. By its ability'
to stimulate the ventricles to greater effort it restores greater tonicity to the
heart, by the prolongation of diastole it can regain its irritability, contracti-
lity and conductivity. These being normal physiological functions of the
heart and each is essential if the heart does its best work and functionates
properly. By its action on the vaso-motor center and the muscular coats
of the vessel wall Digitalis has long been thought to raise arterial tension
and would therefore be contra-indicated in conditions in which the blood
pressure was materially raised. This seems true in animal experimentation
but according to Eggleston in humans this is not the case, certainly in
proper Therapeutic doses.
Digitalis by improving the circulation naturally improves pulmonary
ventilation and respiratory function with a resulting relief of cyanosis and
abolition of the vaso-constrictor effect of carbon dioxide on the center of
respiration. The improved circulation results in better functioning of the
various organs and tissues of the body and therefore tends to restore to nor-
mal the several mechanisms by which the circulation is kept and maintained
at its most effective and efficient level. By stimulating the Vagus both cen-
trally and peripherally Digitalis slows down the running heart to a safe gait
that is best for itself and the other organs which it so materially presides
over. It is like lines on the running away horse, a sort of emergency brake
which is able to check and quiet the irritable, laboring fleeting heart. It
however, is not necessarily an emergency drug for indeed it acts very slowly
and lasts long once it has attained its full and proper physiological effect.
The other chief action of this very useful drug is the value as a diuretic.
It relieves renal congestion however not by any particular action which it
has on the kidney, but by improvement of the circulation.
Heart failure naturally is the result of exhaustion of the cardiac muscle
and cardiac function and this exhaustion may be the result and often is of
persistent rapid cardiac action. It is going a gait it cannot keep. And the
remarkable efficacy of the drug lies in its ability to increase the cardiac
force and slow the rate of the pulse and heart to a reasonable gait which it
can maintain and supply blood over the body as it normally should. When
a cardiac abnormality was found present it has been the custom of many
physicians to blindly give digitalis with no accurate observation as to when
benefit accrued from its use. Its administration therefore was surrounded
by so much confusion and lack of real knowledge of what was going on
that its usefulness and uselessness was never clearly determined and often
the drug was given due credit or discredit was placed upon it. Digitalis ac-
cording to most modern experimenters and careful observers should be giv-
en for effect. There is not necessarily more therefore than a general offi-
cial idea as to the proper dosage. It all depends on the disease and the pa-
tient. An unusually large dose, much larger than the official amount may
be required, effect and results are what is desired by the patient and phy-
sician.
In auricular flutter the allied condition of auricular fibrillation Digitalis
PRACTICE OF MEDICINE 69
finds some of its greatest usefulness and most gratifying results. The flut-
ter of the auricle is said to be more intermittent but may eventuate in the
fibrillatory quivering of the auricle. When the rapid heart is due to fever,
exophthalmic goiter, the infections and intoxications it is said that the drug
has little effect on the heart gait.
The most gratifying and dramatic effects of Foxglove is seen in heart
failure with dilatation of the heart and dropsy. According to leading ob-
servers and authorities on heart disease 80-90% of these cases suffer from
auricular fibrillation and indeed the failure of the heart may be due to or
induced by the very rapid rate of the heart in auricular fibrillation. It
starts very suddenly and dilates. The response to Digitalis in some of these
cases, as you know, is most striking. The patient who has Cheyne-Stokes
breathing, orthopnea, edema, ascites, restless, sleepless with that anxious
peculiar facies seen in these cases, with a heart beat of 120 or more beats
per minute, this distressed patient appears as a new individual once they
have become sufficiently influenced by this drug. They lie down and sleep
quietly, the swelling is gone, everything is different and they are so grateful!
The whole picture has changed, the heart is now beating 70-80 times per
minute, full and of good volume, regular and quiet. Of course, rest, pur-
gation and other things are contributory factors which should be remem-
bered but digitalis is the drug which has essentially changed the picture.
Patients do better in bed when taking the drug and should not suddenly
move about.
According to Sir James McKensie Digitalis does not slow the heart in
Aortic Regurgitation. It has been taught that as the drug prolonged dias-
tole it therefore allowed the reguggitant stream to do more damage by the
return flow this however has not been the experience and observation of the
well known authority in cardiac disease. McKensie states that he has re-
peatedly pushed the drug to full Physiological effect with vomiting with
no slowing of the heart rate.
In Lobar Pneumonia when the heart is tired and has been laboring,
pumping blood through a consolidated liver like lung. Digitalis is often an
invaluable drug and a life saving agency. In cardiac asthenia, the "tired
heart," in the very irritable palpitating heart if it be not due to Gastro-
intestinal disturbance Digitalis is of value- It is the best antidote in
Aconite poisoning. It acts slowly however and ammonia and more fleeting
agents should be used until the drug can take hold. High temperatures al-
ways prevent Digitalis from slowing the heart because as proved by Brun-
ton and Cash fever has a depreissant action on the vagus centers in the
Medulla and also when the temperature is very high the peripheral termi-
nals of the vagus. This is very important and should always be remem-
bered by the busy practitioner.
Of the preparation to use there are a large number from which to choose.
McKensie favors the use of the Official Tincture provided it is fresh and
of a guaranteed strength. The drug should be physiologically tested and
if it is not fresh should not be used. There are more elegant preparations
on the market, many of them proprietary and some fat free and can be used
hypodermically to better advantage. They are much more expensive how-
ever, and this should be remembered in prescribing the drug. Digitalin
70 NORTH CAROLINA MEDICAL SOCIETY
in one fiftieth of a grain is often used. Digitalone (Houghton) is given in
one-tenth grain doses hyperdermically and represents 16 minims of the Tinc-
ture. It is fat free and can be given hypodermically to advantage, is readi-
ly absorbed and is not irritating. Powdered digitalis leaves seem very ef-
fective in one grain doses combined with an equal amount of squill and
mercury and indeed often this so called Guy's or Neymer's pill or the grain
each of calomel, squill and digitalis will give results when all other pre-
parations fail. I have now a woman of 56 years who has had Auricular
Fibrillation with edema, dyspnea and unable to sleep who has been influenced
only by this combination. One has to be careful and not salivate the pa-
tient. And often one is at a loss to know whether the calomel, squill or dig-
italis has been the efficient agent. Some are partial to the Fluid extract.
It does not matter so much, whether one uses the infusion, Tincture, Fluid
extract or some proprietary remedy, they all should be tested physiological-
ly, and freshly prepared. The Tincture and Infusion if fresh are probably
the best two preparations, and should be given for effect and once the
eflect is gained keep it. This is done by stopping the drug when the rate
has fallen to 70-80 beats per minute and give half as much as the rate be-
gins to increase.
By giving and witholding the drug and diligent observation as far as is
practicable and possible the quantity necessary to keep the heart gait at
a moderate and safe level can be found. The patient should, if intelligent,
be instructed to correlate his sensations of relief so that he may acquire a
keen knowledge of when it is necessary for him to take the drug. If this is
done intelligently many patients especially those with auricular fibrillation
may be able to live useful, comfortable lives free from these extreme at-
tacks of heart failure which are so apt to occur in this condition.
The armamentarium of the well informed Physician is not complete un-
less he has a clear knowledge of this drug, when, how and why to use it.
It is one of the most gratifying and useful drugs in medicine. It is a slowly
acting effective cardiac stimulant of first choice in certain cardiac condi-
tions and should only be used intilligently and carefully for its physiologi-
cal effect. If used in this way no danger or deleterious effect need be
feared.
T. E. Anderson : I thank Dr. Speed very much and am certain that he
and Dr. Faison are the only two men here that know anything about it.
DISCUSSION
Jas. M. Northington : I was in a position to follow the details of the
work done on digitalis in the University of Minnesota by Morris and
White. A report of this work had for its object the determination of the
relative potencies of specimens of the drug under different conditions. Speci-
mens grown in the botanical gardens on the grounds of the University
were found to compare favorably with those of English and German
growth obtained through the most reputable channels. Very recently, pro-
bably because of the interest stimulated by a discussion on this subject at
the meeting of the Southern Medical Association, an inquiry as to his meth-
od of estimating doses was addressed to Dr. Eggleston. He replied through
the J. A. M. A. about four weeks ago. It is well worth looking up, as it
PRACTICE OF MEDICINE 71
can be readily made use of by every physician. Practically all investigators
ilong this line are agreed that the Tincture is the most reliable and satis-
factory preparation.
RADIUM IN THE TREATMENT OF SKIN CANCER
Dr. W. D. James, Hamlet, N. C.
The scope of this paper has been intentionally limited to a consideration
of the value of radium in the treatment of cancer of the skin. The value
of this therapeutic agent is obtainable only after all methods of using it
have been tried and the results classified. After a reasonable amount of ex-
perience one is able to regulate the dosage so as to obtain the best possible
results. One cannot prescribe radium in certain number of millegram
hours — as you would prescribe drugs.
In considering the effect of radium on tissue it is important to know
there are three types of rays emitted from radio-active bodies which have
been called alpha, beta, and gamma. Alpha and beta are the burning rays
and are of low penetrating power. The gamma rays are more penetrating
and are not burning or irritating rays. Due to its high penetrating power
the gamma ray is commonly spoken of as the therapeutic ray of radium. It
acts directly on the nucleus of malignant tissue cells and since they are em-
bryonal in nature, such malignant tissue is acted on and destroyed before
the normal tissue cells are appreciably affected by the radium irradiation
The alpha ray is soft and is of no practical value in radium therapy. The
beta ray is of value and should be employed where the radium can be ap-
plied directly to the lesion.
If normal tissues intervenes between the pathology and the surface in
which the radium is applied, one must screen the radium so that the beta
rays are absorbed to such an extent as to prevent radium burn on the nor-
mal skin. Unless the beta rays are cut off by a suitable thickness of metal,
the superficial tissues will be subjected to a much greater action than the un-
derlying layers which may result in a surface injury, or so-called beta ray
burn. Where you can bring the radium in direct contact with the malig-
nant cells and only superficial effects are required the beta rays are very
useful. The resistance of the patient is of importance. The common ob-
servation that in two cases with the same type of growth, subjected to the
same radiation, different results are obtained; that in one the cancer dis-
appears promptly and in the other it is not affected at all, suggests the re-
sistance in the patient. Again you cannot lay too much importance on the
extent of local involvement ; large growths may disappear and small ones
fail to do so. The most easily injured normal tissue is the eye and the
rectum. Radiation carried to the extent of severe injury may defeat its
aim in the end.
In every patient, radiation up to but not beyond the toleration of the
normal tissue should be given. This part of the treatment can be learned
by reasonable amount of experience. The theropeutic value of radium is
based on the fact that the radiations from fadioactive substances, if suffi-
ciently intense are capable of destroying living cells. This effect has proved
beneficial in the treatment of diseased tissue, since the discovery was made
that diseased cells are more susceptible to radiation than normal cells of
1 1 ■ NORTH CAROLINA MEDICAL SOCIETY
health)' tissue. That is, the radium rays exercise a selective action, attack-
ing the diseased cells more readily than the normal ones. By suitable pre-
caution and very simple technique of screening, it is possible with very few
exceptions to effect complete retrogression of a tumor w^ithout injury to the
surrounding healthy tissues. Whether radium is used in the form of a salt
in an air tight container or as an applicator the principle of the technique
is the same.
The compound of radium, preferably the insoluable sulphate is sealed
in a thin walled glass tube, about two millimeters in diameter and in length
no longer than is necessary to hold the firmly packed material. The sealed
glass tube is placed in a silver container with one-half millimeter wall
thickness and the container fits into a brass capsule of one millimeter wall
thickness. These containers serve in the capacity of filters; the silver tube
being used in cases where light screening is indicated and both metal tubes
in cases where most of the beta rays should be absorbed.
Besides the three primary forms of rays already described, there are sec-
ondary rays which are produced when the primary rays pass through the
metal screens. This form of secondary radiation is of no practical value
from a therapeutic standpoint. These rays are comparable to very soft beta
rays and in order to prevent a burn it is necessary to provide additional ab-
sorbing material by surrounding the metal screening with a few millimeters
of rubber dam — a very convenient material for filtering secondary rays may
be found in ordinary unvulcanized tube repair gum as sold by automobile
supply houses.
Generally speaking, the deeper the ulceration or the larger the nodular
mass, the greater the dosage required.
The dosage required in each particular case is readily determined after
certain amount of experience. The factors to be considered are the quanti-
ty of radium used, the time of exposure, the filtration and distance between
radium and the disease tissue. Within certain reasonable limits the same
results may be obtained by increasing the quantity in the same proportion
in which the time exposure is decreased and vice versa, but extreme vari-
ations are not covered by this general rule. You can get the same results
by applying 25 milligrams for four hours as you would by 100 milligrams
for one hour. The expression of dosage in milligram hours is not correct,
because it leads one to think that the only factors which enter into the speci-
fication of a dose of radiation are quantity and time, whereas the filtration
and distance are just as important.
To the beginner in radium therapy the question of filtration seems to be
a difficult problem. Where the radium is in direct contact with malignant
tissue or where the tissue is very superficial, one should use beta rays, and
therefore a screening should be very light; on the other hand if the path-
olog\' is deep-seated or if normal tissue intervenes between the radium and
the diseased tissue, then the beta rays cannot be used to any great amount
and the screening should be heavy. Beta rays are comparatively easily ab-
sorbed and a screen of 2 millimeters of lead for the plaques of half-milli-
meter of silver and one millimeter brass for the tubes with the added rub-
ber damming to screen off secondary rays is all that is necessary for ordi-
nary cases.
PRACTICE OF MEDICINE 73
Distance also is an important factor when the lesion is deep seated and
overlying healthy tissues have to be protected from injury and when a more
uniform radiation is desirable. (For 100 millegrams of radium the dis-
tance for the average deep-seated lesion for 6 hours exposure is 3j^ cm.)
The required distance is obtained by inserting gauze or rubber slabbing be-
tween the radium and tumor. It is to be remembered however that dis-
tance should be only employed when it is impossible to bring the radium in
direct contact with the malignant cells.
In the treatment of epithelioma with radium, one should not insist upon
a certain technique as the only correct one. Equally good results may be
obtained by different methods of treatment. For many epithelioma of
small size and relatively superficial base the following technique may be
used. A varnish apparatus of 1-4 strength may be close. One apparatus
of this type covers 4 sq. cm. of surface and contains about 10 mg. of radium
salt. A silver or lead screen 1-10 mm. thick is placed over the face of the
apparatus to absorb the soft beta rays. Over this are placed six or eight
thicknesses of block paper to absorb the secondary rays which are produced
when the radium rays pass through metal. The whole apparatus is then
enveloped in thin dental rubber dam applied to the epithelioma and held in
place by adhesive plaster. There are 4 exposures of an hour ; each may be
given on consecutive days. The screen is then removed and three or four
similar exposures are given with the apparatus wrapped only in rubber dam.
Following the treatment a slight inflammatory reaction develops. A crust
then forms which corresponds in size to the area of radium applicator.
Under the crust which may be shed and renewed several times handling
takes place in about six weeks from last treatment. Cutaneous epitheliomas
of fungating type are best treated at first with unscreened radium in order
to cut down quickly the fungating portions. In this type of lesion a half
dozen exposures may be given in successive days with above applicator cov-
ered with rubber daih. With the disappearance of the fungating part of
the tumor, the base if deeply infiltrated can then be treated with screened
radium. Another method that may be successfully used in epithelioma of
moderate size consists in giving a single intensive exposure. One may give
an exposure of 6 or 7 hours with 50 millegrams of radium salt screened
with 5-10 mm. of silver. Moderate reaction takes place and recovery en-
sues in about six weeks. For treatment of large epithehomac not less than
50 mg. of radium salt are absolutely essential. We have treated 40 cases
of skin cancer of all kind with 100% apparent cures.
At the next meeting of the North Carolina Medical Society at Pinehurst,
April, 1921, I hope to be able to report a good number of cases of cancer
of the cervix and fundus. Also on filiroid tumor of the uterus and excessive
flowing at and between the menstrual period. We are now working on
six cases of Exopthalmicgoiter with radium and x-ray, which I hope can
also be reported on favorably.
DISCUSSION OF DR. JAMES^ PAPER
Joseph A. Elliott, Charlotte: I would like to express my apprecia-
tion of the exosllent results Dr. James has obtained in the treatment of
skin cancers with radium. There is no longer any doubt but that radium
in the hands of an expert, such as Dr. James results show him to be, is of
74 NORTH CAROLINA MEDICAL SOCIETY
inestimable value as a therapeutic agent. I feel, however, that with equal
skill, xray will produce as good results as radium, in the treatment of skiti
cancers. Where the lesion is located on the eye lid, or in the mouth, we use
radium to advantage due to the fact that it can be placed in close proximity
to the malignant cells. The same holds true of carcinoma of the bladder
or prostate. Little can be expected of xray in these cases as the rays have
to penetrate so much normal tissue before the malignant foci are reached.
On the other hand radium can be placed in direct contact with the growth.
Within the past few years the xray erythema dose, or skin unit, has been
worked out so carefully by suCh men as McKee and Witherbee that one is
no longer in doubt as to the dosage to use. Recently Kingery has worked
out a mathematical curve showing the length of time the ray remains in the
tissues and the rate of absorption. With this knowledge at hand it is easy
to keep the lesion saturated, thereby obtaining the maximum effect from the
ray at all times rather than allow the rays to be completely absorbed before
giving subsequent treatment. To my mind this is a great step forward in
xray therapeutics and I feel that greater results are to be hoped for as a
result of this work.
DOUBLE CHOKED DISCS— OPERATION, WITH RECOVERY
OF VISION.
Henry L. Sloan, M. D., Charlotte, N. C.
Mrs. R. D. G., age 19, Eufala, N. C, first seen on March 16, 1920.
Failure of vision and headaches.
About one month ago patient began to suffer with headaches, and vision
began to fail, and had failed so much that she had to be led into office.
There was also nausea and vomiting, worse in the A. M., and on change
of position — not projectile.
When first seen one month after onset of P. I., patient was in a v-^ery
anxious state of mind ; she seemed to feel as if some calamity were immi-
nent. At all times she was mentally alert and answered questions prompt-
ly. Complained much of headaches, which did not seem severe.
P. M. H.
For a few months before onset of P. I., patient said she suffered a great
deal with rheumatism — which continued up to the time she came to our
office.
F. H.
Of no importance.
PHYSICAL examination
T. p. R.
Normal.
General appearance good. Appetite good, but digestion poor.
Eye findings: O. D. V. Count fingers two inches. O. S. V. Amaurotic;
light perception absent.
Both eyes prominent, but always thus. Pupils widely dilated and did not
react to light. Media clear. Both discs were enormously swollen — show-
PRACTICE OF MEDICINE 75
ing about nine diopters of swelling with many hemorrhages, and with us-
ual contortions of vessels in such condition.
O. D. Ext. rectus showed paresis.
O. S. ext. rectus paralysis with convergent squint.
Nasal examination and xray of sinuses negative. X-ray of teeth, urin-
alysis (repeated examinations) negative. Blood and spinal fluid Wasser-
manns, negative. Leucocytosis — 20,000. Spinal fluid cell count 3, and un-
der pressure, — with monometer, 26. (Normal anywhere up to 10.) Blood
pressure, 128 — 80.
Neurological examination : Has atoxia of both hands. Knee jerks ab-
sent. No clonus.
Treatment: Although rhinologic was negative, we, opened ethmoids and
spnenoids. Negative pathological findings. However, the next day patient
remarked that she was no longer troubled with rheumatism, and was free
of it during her stay in hospital.
Vision did not improve and subjective symptoms of headache and nausea
persisted. Two days later a temporal decompression was done by Dr. Breni-
zer. Soon all symptoms were relieved and vision began to improve and
improved steadily until patient was dismissed from the hospital.
An examination of eyes April 6, showed: O. D. V.r=20-.100. O. S.
V.=20-100.
Practically all retinal hemorrhages had been absorbed and there were only
three diopters of swelling of both discs. Both external recti showed much
improvement of function. Patient went home feeling fine, with useful vis-
ion and with a good chance of much better vision as time passes.
This is a case, probably of brain tumor; which Gushing tells us will be
found much oftener if we only look for it. With refined methods of diag-
nosis they were found to be much more frequent, than old statistics indi-
cated in the records of Johns Hopkins Hospital.
Other causes of choked discs are nephritis, syphillis, basilar meningitis,
supperative sinusitis, and echinoccus cyst of brain, disseminated sclerosis,
eta These could be practically all ruled out in this case. Choked disc in
brain tumor is present in about 80 per cent of cases.
Given a case with symptoms of headache, nausea and vomiting, we should
make a careful examination of the visional fields. Dyschromatopsia (in-
terlacing and inversion of the color fields) is a much earlier sign of brain
tumor than choked dies. This sign can be easily demonstrated. In its most
typical form, the blue field is interlaced and may become completely inver-
ted with the red. There may be blue scotoma or a total achrom-atopsia for
this color alone. And many other varieties conforming somewhat the type
mentioned above. We have been taught that such perimetric findings are
pecular to functional and hysterical states. That such color field changes
are due to increased intracranial pressure has been shown by rapid restora-
tion of normal color values in the fields of vision after relief of the pressure.
So I would urge use of these examinations under such circumstances.
Of course, in the case here reported the possibility of any helps from tests
dependent on good vision was precluded. But they could have been done
earlier.
76 NORTH CAROLINA MEDICAL SOCIETY
Given a desperate case of the character here reported, I would urge cran-
ial decompression as an emergency measure to conserve vision. Then look
for the cause later. This operation is not necessarily heroic or dangerous.
In conclusion, one purpose I have reporting this case is to emphasize the
importance of ophthalmology as an aid to general medicine. The eye is an
outgrowth from the primary forebrain, and is very closely related to many
pathological brain changes. We are very fortunate in having many of our
medical men quite alive to this fact.
Much valuable information can be had in the diagnosis of intracranial
lesions in the earlier stages by use of ophtholmological examination, and we
feel that it should be made use of more often in such conditions.
Note: Patient was seen finally on June 8th, 1920.
Vision: O. D. V.=20-40 minus 1. O. S. V.=20-70 plus 1.
Both discs had lost all their swelling. There was slight bilateral papil-
lary palor. Both external recti had regained normal function. In fact, pa-
tient felt quite well.
DIFFERENT FORMS OF FOOD ADULTERATION.
W. M. Allen, Charlotte, N. C.
State Chemist of North Carolina.
Food adulteration had its origin in very early ages. Even when society
was in a very primitive state there were knavish tricks in bartering, substitu-
tions of bad for good and falseness of many kinds. There was not room for
so much adulteration then for the food of the family was raised from the
soil on which they then dwelt and was prepared for use by themselves and
commercial frauds on a large scale had not developed. There are, however,
records of ancient sophistications practiced by the Greek and Roman traders,
but it was the Middle Ages that the most interesting types of these practices
developed.
About the first fraud alluded to in the early writings was the adulter-
ation of opium. The test was primitive and crude. If pure it burned with
a clear, brilliant flame; if adulterated the flame was dififerent. Its quality
was judged by its behavior when exposed to the sun.
In some very early writings we find frauds practiced by bakers alluded
to. They added to bread a white earth, soft to the touch and sweet to the
taste, w'hich was supposed to have been obtained from a hill situated near
Naples.
The adulteration of wine in Athens necessitated a special inspector, whose
duty it was to detect and stop such practices. Greek history mentions Can-
thon, who excelled in ingenious mixtures as he knew how to impart to new
wine the flavor of aged wine. In Rome and Gaul wine was adulterated in
the cellars with artificial color and flavor.
In Europe generally from the eleventh century on bakers, brewers and
vinters were frequently accused of corrupt practices.
By the "Assize of Bread" during the reign of John the sale of bread was
regulated in England, the regulation of the price, by limiting the profits of
the baker so that the price of the loaf should bear a certain relation to the
PRACTICE OF MEDICINE 77
price of wheat. The Assize of John's reign continued in force until 1286
when it was repealed by "The Statute of Assize."
There were various modifications of the assizes, and they were finally
abolished in 1815. Though preventing adulteration with foreign substan-
ces was not the main object of the regulations, as time went on and the
sins of the bakers accumulated, clauses with regard to the adulteration of
bread with foreign matter were inserted and the later ones developed into
the "English Sale of Food Act." The assize of 1582 contained the follow-
ing: "If there be any that by false means useth to sell meal; for the first time
he shall be grievously punished, the second time he shall lose his meal ; the
third he shall forswear the town and so likewise the bakers that offend.
The assize of 1634 contained stringent regulations with regard to musty
meal. If there be any manner of person or persons, which shall, by any
false ways or measure, sell any musty meal unto the king's subjects, either
by mixing it deceitfully or sell any musty and corrupt meal, which may be
to the hurt and infection of man's body, or use any false weights, or any
deceitful ways or measures, and so deceive the king's subjects, for the first
time he shall be grievously punished, the second he shall lose his meal, for
the third offense he shall sufFer the judgment of the pillory, and the fourth
time he shall forswear the town wherein he dwelleth.
It is recorded in "Doomsday Book" that during the reign of Edward the
Confessor that a knavish brewer was taken round the town in the cart in
which the refuse of the place had been collected, and to that was added
corporal punishment.
In many towns in the sixteenth century there were "ale-tasters" whose
duty it was to inspect the beer. For example, the Mayor of Guilford
ordered that the brewers make a good useful ale, and that they sell none of
it until it be tasted by "ale-tasters." The ale was not only tasted, but it
was otherwise tested. Some of it was spilt on a wooden seat, and on the wet
place the taster sat, attired in leather breeches. If sugar has been added,
the taster's leather trousers would stick to the seat ; if sugar had not been ad-
ded, the dried extract, having no adhesive property the trousers would not
stick. In France and Germany during the Middle Ages as in England, the
regulation of the sale of allimentary products applied almost exclusively to
meal, drugs, wine and beer and the punishment in France was very similar
to that of England except in France it partook more of the character of a
religious penance. In Germany the punishment was decidedly more severe.
All who adulterated food or drink were punished severely, with painful
and dishonoring penalties, such as public exposure of the fraud and whip-
ping at the gate. There are instances recorded where for adulterating
food or drink the culprit was burnt at the stake or buried alive.
From these extracts we see that food adulteration and laws to prevent
same are not wholly products of modern times, but are inheritances of early
Middle Ages, but no interest was taken in the subject during the early
years of this country.
About the first legislation of this nature in the United States was an act
of Congress in 1848 to secure the purity of imported drugs.
In about 1877 laws to prevent the sale of adulterated food were passed
78 , NORTH CAROLINA MEDICAL SOCIETY
in some of the States like New York, Massachusettes, Michigan and New-
Jersey and chemists commissioned to investigate and report on the subject.
Some most excellent work was done in those states and from time to time
other states followed their example.
In about 1879 a bill for Federal regulation of food in interstate commerce
was introduced into Congress and during the years following similar bills
were introduced but opposing interests were so strong that not until 1906,
after the horrible exposures of the Chicago and other packing houses could
such bill be passed-.
During the first hundred years of the history of this country practically
no effort was made to prevent food adulteration and the sophisticator and
adulterator of foods had full sway. Their actions were regulated only by
their own conscience Avhich if they ever had, became so paralized that their
nefarious businesses were not interfered with much, and the food sold to
the American people during that latter part of that period would have made
a monkey blush.
Food adulteration was not so bad in the South as it was in the North
and consequently the Southern States were slow to pass food regulation
laws.
Our own good state was about the first to take such action and in 1899
passed a law which in 1907 was redrafted and passed and with some amend-
ments is our present food law. So far as intentional adulteration is con-
cerned the law is effective but not so much was known at that time about
sanitation and from a sanitary standpoint it needs revision.
The Legislature passed a good law and made it the duty of the Depart-
ment of Agriculture to enforce it without however providing any funds for
the purpose. Practically the same thing followed in several of the other
Southern States.
The funds of the Department of Agriculture were from an inspection
tax on fertilizers and were therefore paid in by the farmers of the State.
The Board of Agriculture, made up of farmers, did not see fit and would
appropriate but little from a fund paid in by one class of people for the en-
forcement of a food law that would benefit them much less than it would
the people who depended wholly upon bought food for their living.
For several years less than $2,000.00 a year was spent for all purposes of
food law enforcement while many other states were spending from $10,-
000.00 to $40,000.00 a year for such work.
At our solicitation since that time other inspection laws like the oil and
gasoline laws, the linseed oil laws and the bottlers plant inspection law,
etc., have been passed that produce revenue for the enforcement, and by
doing the food yvork in connection with the latter fairly reasonable funds
are available for the food work, but no funds specifically for food work are
provided.
But more to the subject, food is that which, taken into the body, builds
tissue or yields energy.
Food is adulterated : If it contains any added poisonous or other added
deleterious ingredient which may render such articles injurious to health.
PRACTICE OF MEDICINE 79
If it consists in whole or in part of a filthy, decomposed or putrid animal
or vegetable substance.
If any substance has been mixed or packed with it, so as to reduce or
lower or injuriously affect its quality or strength.
If any substance has been substituted wholly or in part for the article.
If any valuable constituent of the article has been wholly or in part ab-
stracted.
If it be mixed, colored, powdered, coated or stained in a manner wholly
damage or inferiority is concealed.
Then the effect of adulterated food on mankind is studied from two
standpoints. First, the effect on the health ; and second, the effect on the
wealth. A very small amount of adulteration will have a tremendous accum-
ulative effect on either our health or our wealth. Then the adulteration of
food comes under two general heads :
1st. Adulterants which are harmful or deleterious and effect health, and,
2nd, Adulterants which are fraudulent and only affect the cost.
The first may be divided into two classes: Those things that are of
themselves, when added to food, deleterious or which when added to food
render the food deleterious and are added intentionally in its manufacture
to preserve it; or to color it to improve its appearance, and those things
which occur or get into the food incidentally in the manufacture of same,
owing to the use of spoiled or inferior material or insanitary conditions
under which it is manufactured or handled.
Under division one, sub-division one are chemical preservatives and pois-
onous coal tar and certain other mineral colors. When the food laws were
first passed chemical preservatives such as benzoate of soda, borax, salicylic
acid, certain sulphites and even formaldhyde were used premiscuously in
all kinds of foods and many were colored with poisonous dyes. The object
of the color was to deceive the purchaser.
Inferior, and even spoiled materials, were chemically preserved, artifici-
ally colored and flavored and sold as high class products and because of the
flavor and color the true nature was not at all evident.
The use of these products was doubly objectionable. It made the use
of more or less spoiled material possible that would otherwise have been
easily detected, and, while the amount of the preservative or color consumed
at any one time was so small that its poisonous effect on the body was neg-
ligible, it was enough to preserve the food and therefore to a certain extent
interfere with the action of the digestive ferments of the body and retarted
digestion.
Under food law enforcement, the use of these preservatives and coal tar
colors in food have practically disappeared, but it was not without a fight,
and a hard fight too, for they died fighting. It was difficult to get evidence
regarding their effect on the body that the courts would accept. Actual
test had to be made by the Referee Board. The test was a long tedious
process and not very satisfactory at best, but the results all taken together
showed preservatives in food to be more or less objectionable, and the re-
sults, while not conclusive, did aid in breaking up the practice.
Another kind of adulterants that effect health are bacteria and products
80 NORTH CAROLINA MEDICAL SOCIETY
that are the results of bacterial action. They are not intentionally added
to food, but get into it incidentally from the use of bad, decomposed mater-
ial, or by careless or insanitary manufacture or handling.
I shall not attempt to discuss the possible effects of bacteria on health;
that is the field of the physician, but will in a cursory manner refer to
ptomaines about which, however, very little is known. They are of bacter-
ial origin and are very poisonous. Not always but for some reason they are
sometimes formed in the decomposition of organic matter. Ptomaines are
formed only in nitrogenous matter, and rarely in matter except of animal
origin.
Ptomaines are a class of arganic bases or putrefective alkaloids formed by
the action of putrefactive bacteria on nitrogenous matter. Chemically
speaking they are derivatives of ethers of the poly hydric alcohols. Some
of them have been prepared synthetically. Authorities seem to differ as to
whether they are all poisonous or not, but it is well known that most of
them are exceedingly poisonous. But one thing that I wish to call to your
attention is that ptomaines cannot be reliably detected chemically, that is,
there is no chemical test for ptomaines, that can be relied upon. The only
way to detect any of this class of poisons is to test same on a living animal.
That may be done by either feeding the suspected specimen to the animal
or by injection. It is our practice in the Food Laboratory to feed it to the
animal.
It appears that almost any animal is sensitive to ptomaines. Cats, rats
and guinea pigs are all desirable subjects. Rats being pests that will eat al-
most anything and fairly easy to obtain are used most, but Pussy has fared
badly at times at our hands when we had to test for ptomaines.
A few years ago a catch of fish were allowed to get bad before they were
pickled at Morehead City. Ptomaines were formed in them and before
that fact was known they were pickled, mixed and packed with a large lot
of good fish. When they were later put on the market several people were
made ill from eating the fish. The matter was reported in the papers. We
immediately secured samples. Some of the fish proved to be bad. By wire
we had the shipper trace each shipment and stop sale of same until an in-
vestigation could be made. Samples from about forty barrels were ob-
tained. Some of them proved to be bad while others were good ; even diff-
erent fish from the same barrel, one would be bad and another good. The
bad were so mixed with the good that it was impossible to separate them
and several hundred barrels had to be condemned and sent to the fertilizer
factory.
We used chemical tests described in the books, as we had done before,
but again found them unreliable. We examined them physically but after
being pickled there appeared to be no positive difference in the appearance
or odor by which we could tell the good from the bad. No salt fish smells
good and if any smelt worse than any other we could not detect it, but some
of the fish when eaten by a cat or rat would make it very sick from which,
in some instances they died, while some of the other fish did not seem to
affect them at all.
The packer of the fish was unable to account for the bad fish unless they
PRACTICE OF MEDICINE
81
were mixed in with good fish by the fisherman from whcm the fish were
bought, so that they escaped detection.
Some of you no doubt saw in the Associated Press reports within the past
few months, references to sickness and death in several instances, from the
eating of infected ripe olives.
' A government report shows that a shipment of these olives were seized
first by the Food Inspector in Wisconsin. The government alleged that
the olives were adulterated in that they consisted in part of a filthy, de-
composed and putrid vegetable substance. Examination by the Bureau of
Chemistry showed that guinea pigs fed on olives from the shipment died,
indicating the presence of toxin due to decomposition of the olives by bacter-
ia which were later identified as Bacillus botulinus. Olives similarly in-
fected were responsible for the death of several people within the past few
months in Canton, Ohio; Detroit, Michigan; Brooklyn, New York; Mem-
phis, Tennessee and elsewhere.
Investigation showed that defective methods in processing, pickling and
padking the ripe olives were responsible for the infection.
The government report further states that all the ripe olives to which
trouble has been attributed were packed in glass and that the trouble was
probably due, for fear of breaking, to insufficient heat to sterilize the pro-
ducts. The poison would of course develope in tin containers if they were
not sufficiently processed, but as there is no danger of breakage in tin, a
sufficient degree of heat is usually applied.
In all cases of botulinus poisoning investigated, the ripe olives showed
signs of decomposition. They had odor and taste characteristic of decom-
position that indicated that they were not sound. In some instances even
where death resulted, the persons who served the olives and persons who ate
them recognized that the olives were not sound.
Then, there appears to be no necessity for one to live in dread or fear
of being poisoned by unconsciously eating dangerous food, or food in which
ptomaines have formed.
There are, however, cases where the real character of the product is hot
evident from its physical appearance, a good example of which is a beverage
containing ethyl and methyl alcohol. A beverage containing ethyl alcohol
might contain a dangerous amount of methyl or wood alcohol without the
presence of the latter being evident from its taste or odor, though the taste
and odor of the meth}^ alcohol is quite different from that of ethyl alcohol.
As is well remembered, only a few months ago there were a number of
deaths from the use of methyl or wood alcohol in drinks. Wood alcohol
is so deadly poisonous that it can't be used to any great extent as an adulter-
ant or substitute for ethyl alcohol in beverages for it will tell its own story
in very sad terms. However, there is another use to which it is put as an
adulterant or substitute for ethyl alcohol, which, while objectionable, is
not so fatal as if used in a beverage. That purpose is the use of it as a
solvent in extracts, perfumes and lotions which, if taken internally at all,
is in very minute quantity, not enough to tell the story at once, and this
fact makes its use more possible for this purpose and in the long run, upon
a whole, vastly more dangerous.
82 NORTH CAROLINA MEDICAL SOCIETY
Another example of a substitute which is both fraudulent and deleterious
to health and the presence of which in food is not evident because of its
taste or odor, is the use of saccharin as a substitute for sugar. Saccharin as
a substitute for sugar in food is far less dangerous to health than is true in
the case of wood alcohol, so far as immediate results are concerned, but in
the long run it is possibly an even greater curse because its effect is not
so evident, which makes its use vastly more possible and much harder to
prevent. As a substitute for sugar it plays a double roll, and if permitted
by the food laws, its use would doubtless be carried to an enormous extent
during the present scarcity and high price of sugar.
Saccharin is a Benzoylsulfonic imide, and while it is sweet, it has no re-
lation to sugar at all. It is in no sense a food and supplies no energy or
nutriment to the body when used in food. Its use as a substitute for sugar
is not only a fraud but is more or less deleterious to health, according to the
findings of the Referee Board, Food Inspection Decision 135, by the Secre-
taries of the Treasury, Agriculture and Commerce and Labor of the
United States, adopted April 26th, 1911.
Another class of food adulteration consists of adulteration that is fraudu-
lent only and does not affect health. It is adulteration that reduces or
lowers the value or strength of the product without rendering same dele-
terious to health.
From the foregoing it is evident that food adulteration that is deleterious
to health is of all importance, for life itself without health is hardly worth
living. It has been said that that depends upon the "liver," and as physi-
cians you know how important the "liver" is.
As so much depends upon health for our happiness it is impossible to com-
pare the importance of the two classes of food adulteration, but I do desire
to convey to you some idea of the importance of food adulteration from an
economic standpoint.
It is estimated by food officials that in point of volume or frequency of
occurrence that well above 95 per cent of the food adulteration in the Uni-
ted States is from an economic standpoint, the object of which is to gain by
fraud in the substitution of a cheaper, or less expensive, or less desirable pro-
duct for one of higher price.
If not of more importance to health and happiness of the human family,
this class of food adulteration is vastly more voluminous than adulteration
that is deleterious to health. It is a broader field and offers greater reward.
Many dealers and manufacturers will accept profits from this class of adul-
teration that ■would not knowingly sell a product that was deleterious to
health. In fact, it is sometimes hard to make even fairly intelligent dealers
understand that a product can be adulterated and misbranded and its sale
absolutely illegal, when if the same product be properly branded and repre-
sented to be what it actually is, and nothing else, that iti sale is perfectly
legal. They say, well, if it is adulterated forbid the sale of it and I will
throw it back on the jobber or manufacturer. That dealer may be selling
at retail, a compound vinegar or a skim'milk cheese as vinegar or cheese, as
the case may be, when the product as he bought it is properly branded but
his customers never see the original package. Compound vinegar is not de-
leterious to health but it is not vinegar and is not worth as much as vinegar.
PRACTICE OF MEDICINE 83
Vinegar is a product made from the juice of apples and has a delightful
appetizing fruit flavor. Compound vinegar is made from almost any kind
of waste sugar or starch material, like stale bread, etc. Skim milk cheese is
a good food, rich in milk proteids, but it is not as good as cheese which is
made from whole milk without having any of the fat removed. If sold as
skim milk cheese the sale of such a product is all right, but it should not be
sold as cheese.
Corn syrup is a good food but it is not as choice as cane syrup, so a mix-
ture of the two should not be sold as pure syrup.
Cane syrup is a good food but it is not as choice and will not sell on the
market for as much as maple syrup, and if it is added to maple syrup its
presence should be made known to the purchaser.
Nut butter and oleomargarine are good foods but you don't want to pay
the price of creamery butter for them.
These examples could be extended or multiplied almost indefinitely for,
to be sure, for every high class food product there is some way of adulterat-
ing it or of substituting fraudulently some less valuable product for it and
so doing it that the fact is not evident on the face of it. Even bread, the
staff of life, has been greatly misrepresented. Low grade flour from which
it was made was bleached to appear like a high grade.
As manufactured by modern machinery high grade flour is white and it
is bought and sold on its color or lack of color. When a lower grade flour
is bleached to appear like a higher grade it is misrepresented, unless the fact
that it has been bleached is made known to the purchaser.
The law requires flour, if bleached, to be labeled bleached, so that the
purchaser may know that it is not necessarily high grade because it is white.
Food officials have not had easy sailing in the development and enforce-
ment of food laws. Every effort has been fought hard by those who profit
by fraudulent practices in the adulteration and misbranding of food pro-
ducts. They have able chemists and lawyers to study their work minutely to
direct and protect their practice.
Like the patent medicine people they are thoroughly organized and stand
shoulder to shoulder. When you touch one you have touched all and the
whole tribe is on you.
In conclusion, I will add that it is to be hoped that in the near future Dr.
Rankin and the Board of Health may secure legislation that will require
the proper branding of drug products.
I thank you for your attention.
BLOOD CHEMISTRY IN NEPHRITIS.
Dr. W. M. Copridge, Durham
Researches in biological chemistry have wnthin the past few years added
much to our knowledge of pathological conditions. Almost no department
of medicine has missed the benefits of the work of such men as Folin and
Dennis, Dakin, Meyers and others. In the diagnosis of nephritis we find we
have been especially favored by the researches in the so called "Micro-
Chemical" methods of blood analysis. The subject of nephritis has received
84 NORTH CAROLINA MEDICAL SOCIETY
new light where our knowledge of the subject has been perhaps most dis-
astrously clouded, and that has been in the early diagnosis of the conditions.
Formerly physicians have used, most largely, the chemical and microscopi-
cal examination of the urine as an index to the extent of pathology in the
kidney. The limitations of these methods have long been known. It is a
fact that the work an organ is doing cannot be entirely interpreted by the
evident extent of pathology in that organ. Again, the demonstrable patho-
logy of the organ is not always in proportion to the work the organ is doing.
McQuarrie and Whipple have shown that in proteose intoxication the renal
function is very markedly lowered without any demonstrable anatomical
lesions in the kidney. So we have come to realize that the interpretation of
albumen and casts in the urine is usually that of pathology in the kidney
but now we know that we can little judge the function of the kidney by the
presence or absence of them.
Since the time of Bright many attempts have been made to estimate the
amount of work the kidney is doing, by the use of some substance that may
be given in measured amounts and can be recovered in definite amounts in
the urine. To this end, many substances have been used — Methylene Blue,
lactose, salt, water and many others. Roundtree and Geraghty in 1910 in-
troduced phenolsulphonpthalien for this purpose. Without any doubt this
method of studying renal function has been the most generally useful and
must be considered a great step forward in these studies. It seems that it
is the best substance yet derived for fairly accurately determining, for the
time, the work the kidney is doing. It does not tell us that the kidney is ex-
creting a measured amount of the dye hour by hour and day by day over
any considerable period. Neither does it tell us that the kidney is handling
the substances such as urea, creotinine or uric acid, in the same proportion
that it excretes the pthalien. So, as valuable perhaps as any excretory test
may be, the pthalene test has its limitations. The idea of examining the
blood for evidence of renal impairment was conceived many years ago. The
methods used did not permit of any practical use until 1913 when Folin and
his workers devised the comparatively simple methods now in use. The
work of Meyers and Fine, Mosenthal, Marshall, McLean and others have
shown the great practical value of the methods in the early diagnosis of neph-
ritis and also of the prognosis of the disease. Generally in uncomplicated
nephritis, the blood chemistry findings have run parallel to the phalian test
again emphasizing the great value of the latter. In some cases, however,
the Chemical analyses have shown that the pthalian test cannot be relied
on for the same extent of accuracy as the chemical examination of the blood.
In general the examination of the blood for evidence of impaired renal
function has been concerned with the ammonia nitrogen, total nonprotein
nitrogen, urea, uric acid and creatinine. It has been found that the latter
three — the urea, uric acid and creatinine give more information. Studies in
blood urea probably superceded uric acid and creatinine, it naturally being
thought that since the bulk of the nitrogenous waste was eliminated in the
form of urea, that in cases of impaired kidney function retention of this sub-
stance would serve as an index to the extent of the injury.
Marshall, by the introduction of his urease method of determining the
urea of the blood, made It possible for this test to be done with ease in a very
modestly equipped laboratory. McLean has called attention to the value of
PRACTICE OF MEDICINE 85
comparing the blood urea readings with the urea content of the urine, much
in the same method as that of Ambard. This method seems to be very much
to be preferred when considering the question of urea. We know that diet,
exercises and other factors play an important role in the urea content of the
blood. The amount of urea in the blood therefore varies through fairly
wide limits even though the kidney may be excreting a normal amount of
the substance.
The part which the liver plays in the production of urea is unquestionably
a large one, whether all of the urea is formed in the liver or not is an open
question with the favor being on the side that the muscles and other tissues
do form possibly a small amount of the substance. Shroder, with experi-
ments on dogs has done much to show that the liver forms most of the urea.
Pawlow has shown that when the liver is practically destroyed the urea in
the urine is greatly diminished. It seems, therefore, that the activity of the
liver must also be considered in interpretating blood urea readings.
We have, in the Watts Hospital laboratories, felt that in certain cases
with low blood urea readings where renal functions was definitely low, we
have been able to ascribe such a condition to injury to the liver. One case
in particular which seemed to carry this point, was one of bichloride poison-
ing. About 30 grains of bichloride had been ingested about 24 hours be-
fore the observations were made. The urine was scanty, loaded with albu-
men and casts, with the pthalien practically zero in two hours. In such a
cases even with so short duration we would certainly have expected blood
urea readings considerably above normal. As a matter of fact the urea was
decreased, being between 15 and 20 milligrams per 100 cc. of blood whereas
the normal lies between 20 and 40 milligrams. This reduction we ascribed,
without any direct proof, to liver injury due to the bichloride, resulting in a
decrease in liver function coincident to the kidney injury and resulting de-
crease in kidney function.
In cases of toxemia of pregnancy we have found at times the same occur-
rence. We have seen cases with very low pthalien outputs with blood urea
figures about normal or below. Knowing as we do that liver injury is very
often severe in these cases we have again ascribed the low blood urea reading
to low liver function. In several cases we have felt that the blood urea es-
timation has helped us to differentiate the cases of acute nephritis complica-
ting pregnancy, from the cases of true violent toxemia of pregnancy. In
this last group the urea of the blood is not markedly increased although the
kidney function as measured by the pthalien test may be as low as 10-15%
in 2 hours. We have noted that the outcome in such cases not so favorable
as the cases showing low pthalien with high blood urea — showing as we be-
lieve that the cindition in the latter cases is an acute nephritis which is pro-
bably not complicated with liver injury. As, I have said above, these obser-
vations have been only dinical in their nature and have been made on a
comparatively small series of cases and therefore may be erroneous if ana-
lyzed experimentally. Nevertheless, they have practically convinced us that
in cases with severe liver injury the blood urea reading will very probably
be low. We feel that in several cases of suspected toxemia of pregnancy
the blood urea and pthalien tests have helped us to decide which cases were
really acute general toxemia of pregnancy and those of acute nephritis com-
plicating pregnancy.
So NORTH CAROLINA MEDICAL SOCIETY
In chronic nephritis and in acute uncomplicated nephritis the blood urea
is usually increased very often to 100 or more times the normal. These cases
usually, but not always show a corresponding decrease in the output of ptha-
lien. A very interesting case was reported by Halsey in which the urine
showed no albumen or casts and the patient in apparently very good condi-
tion. Examination showed a zero pthalien output with tremendous nitrogen
retention with death in about 3 weeks.
The variability of the blood urea has called for the introduction of the
estimation of the other more constant substances of the blood. Uric acid of
the blood is derived partly from exogenous sources but also from enogenous
sources as well. It is claimed by Chase and Meyers uric acid is the most
difficult of any of these substances for the kidney to excrete. They report
that in consequence of this fact uric acid is the first substance to be retained
in case of kidney injury that it is the most valuable test in order to deter-
mine the incipient cases of nephritis. Their observation is to the effect that
creatinine is the easiest substance for the kidney to eliminate and accordingly
place very high prognastic value in the creatinine estimation. A high crea-
tinine reading being indicative of severe and probably fatal kidney injury.
It is a well established fac(t that practically all types of nephritis are ac-
companied by an increased hydrogen content of the blood. The retained
products in nephritis seem in some way to depress oxidation in the tissues to
the extent that half way product* of an acid nature are the results. Often
this retention of acid becomes of serious import — a vicious circle being form-
ed — the retention of acids causing more kidney damage and vici versa. It is
therefore of importance to know the degree of acidosis. There are several
ways in which this may be determined. The carbon dioxide content of al-
veolar is perhaps the best index. For this determination Marriott has de-
vised a simple method and Van Slyke has devised a more elaborate method
in which the carbon dioxide combining power of the blood plasma is deter-
mined. In practically all cases of nephritis these tests show somp degree of
acidosis. A very simple and perhaps crude method of determining the de-
gree of acids is that of Sellards in which we administer sodium Bi Carbon-
ate in 5 grams doses — normally this amount of sodium bicarbonate will cause
the urine to become alkaline. If after the ingestion of this amount of sub-
stance the urine remains acid, it is indicative of an acidosis.
The practical importance of the blood chemistry analysis is hardly to be
overestimated. Very often cases supposed to be mild cases of nephritis will
be found to be serious when studied by these methods. Impending uremia
may often be prevented when it is recognized early and the patient is taken
thoroughly in hand.
We believe that one of the most fruitful fields for more careful study of
kidney conditions is in pregnancy. There is no more distressing class of
cases than those in which the pregnant woman apparently suddenly goes in
to a state of acute toxemia. Whether the exiology of the condition lies pri-
marily in the kidney or not it is certain that the prognosis is much better
when the kidney condition has received attention all thru the term. With
the function tests and blood chemistry we are enabled to fairly accurately
ascertain the extent of kidney injury early in pregnancy and to prevent in a
large number of cases the serious renal complications. It is certain that fre-
PRACTICE OF MEDICINE 87
quent blood chemistry analyses combined with the pthalien test will act as
an excellent guide to the prophylaxis and treatment of the condition. We
have in the past month seen a case of a pregnant woman of 3 months dura-
tion, who according to her physician had shown no albumen in her urine
previously, and after eating a hearty meal at night went into toxemia with
convulsions the following day. In such a case it is quite possible that had
facilities allowed her physician to have had kidney function and blood chem-
istry analyses on his patient, her true condition would probably have been
known and the proper prohylaxis adopted. Incipient or early nephritis
is of interest to the surgeon as well as medical man. Blood chemistry analy-
ses will often help the surgeon in his decision as to whether "the kidneys can
stand an anesthetic." It is possible that the surgeon can materially lower his
percentage of cases or uremia following ether or chloroform if he is assist-
ed by blood chemistry analyses in making his decision.
1. McQuarrie and Whipple — Journal of Experimental medicine, April
1, 1919. Vol. XXIX No. 4 pp. 421-444.
2. Meyers and Fine — Journal Bialogical Chemistry, 1915 Vol. XXL,
pp. 389.
3. Mosenthal and Lewis — Journal Am. Medical Assn., Sept 23, 1916.,
Vol. LXVII, No. 113, pp. 933.
4. Marshall— Journal Bialogical Chemistry, 1913, Vol. XIV, page 283,
Ibid, 1913, Vol. XV, pp. 287 and 495.
5. McLean— Journal Am. Med. Assn., Feb. 5, 1916, Vol. LXVI, No.
6, pp. 415.
6. Shroder — Achiv. F. experimentelle Pathologic and Pharmakologic 15,
364, 1882 and 19,373, 1885.
7. E. H. Halsev— Journal Am. Med. Assn., June 10, 1916, Vol. LXVI,
No. 24, pp. 1847.
8. Chase and Meyers— Journal Am. Med*. Assn., Sept. 23, 1916, Vol.
LXVII, No. 13, pp. 929.
9. Marriott, Arch Int. Med., 1916, Vol. XVII, p. 840, Journal Am.
Med. Assn., 1916, Vol. LXVI, p. 1594.
10. Van Slyke — Unpublished data.
SURGERY
ACUTE PANCREATITIS RESEMBLING ACUTE INTESTINAL
OBSTRUCTION REPORT OF CASES.
Eugene B. Glenn. Asheville, N, C.
Mr. President and Gentlemen:
Deaver stated in 1918 that he believed it is no exaggeration to say that
acute pancreatitis is more often unrecognized than it is diagnosed before op-
eration, in the first place, because it is comparatively infrequent, and there
is no sign of symptoms that can be said to be pathognomonic of the disorder.
Generally the desperate condition of the patient makes operation imperative
without the formality of a definite diagnosis. Also, acute pancreatitis is as-
sociated with cholecystitis, perforating cholecystitis, perforating gastric or
duodenal ulcer, appendicitis, etc.
As a predisposing factor, obesity and alcoholism are some times mentioned.
Age and sex do not seem to play a part. While somewhat more common
between the ages of 25 and 50, it occurs at all ages. McPherdan reports a
case 9 months old. In 91 cases analyzed at to sex, there were 59 males and
32 females, while in Deaver's series of 15 cases, 11 were females.
In 1889, Fitz named, defined, and classified acute primary interstitial
pancreatitis, a disease the effects of which have been recognized since 1641.
Douglas states that neither the character of food nor the manner of eat-
ing, syphilis, or occupation can be regarded as predisposing causes.
The frequency with which pancreatitis occurs in obese patients, a large
portion of whom become rapi.dly fat, has led to the probably erroneous sug-
gestion of a casual relationship. Robson asserts that the immediate cause of
the various forms of pancreatitis is bacterial infection, clinical observation
and clinical work in a great measure sustain this position. In numerous in-
stance, the most careful bacteriologic search has failed to demonstrate the
presence of micro-organisms even after a fatal, destructive pancreatitis.
These notable exceptions justify us in accepting with some reservation the
sweeping statement that pancreatitis is always an infection process. Reason-
ing by anology, it is probably true, yet unproved.
"A sudden acute abdominal seizure, pain overwhelming, in an apparent
healthy, usually obese individual, accompanied by incessant vomiting, upper
abdominal distension, a transverse resistance not easily elicited, weak pulse,
sub-normal temperature, collapse, and sometimes cyanosis, should suggest
acute pancreatitis." (Deaver.)
Osier quotes Fitz and says: "Acute pancreatitis is to be suspected when
a previously healthy person, or suf¥erer from occasional attacks of indiges-
tion, is suddenly seized with a violent pain in the epigastrium, followed by
vomiting and collapse, and in the course of twenty-four hours by a circum-
scribed epigastric swelling, tympanitic or resistent, with slight elevation of
temperature, circumscribed tenderness in the course of the pancreas, and
tender spots throughout the abdomen, are valuable diagnostic signs."
SURGERY 89
Edsall, of Philadelphia, thinks that all urinary tests combined have little
value in suspected pancreatic disease, as contrasted with careful clinical con-
sideration of the cases. The only test that appears to him to be of any real
value is that for Glycosuria, and this is in very many cases negative- If pos-
itive, however, especially if there are focal abnormalities present, the re-
sults add decidedly to the evidence in such cases.
On account of the obstinate constipation at first, in the acute cases, it is
hard to obtain a fair specimen of fecal contents.
Patients in whom the extravasation of pancreatic juice has caused fat
necrosis are least likely to recover.
The surgery of the pancreas must be directed to providing an escape for
the highly toxic pancreatic fluid ; in other words, the pancreas must be
drained.
Deaver is not always in favor of operating in a state of profound shock;
he deems it wise to wait for a short time, in order to give the patient a
chance to rally, and to wait for the peritoneal inflammation to localize. In
the interim, Murph3'-Fowler-Ochsner method treatment is instituted.
Early operation is desirable. The presence of blood fluid exudate in the
pancreas requires incision and packing with gauze. Too free and indis-
criminate an incision presents the danger of free hemorrhage, difficult to con-
trol. Scarification of the peritoneum over the gland, should, however, be
sufficient to allow gauze drainage to be brought into direct contact with the
surface. A few blunt punctures of the pancreas are of service in providing
free exit for the contained blood, lymph, and the obstructed secretion.
Two routes may be chosen, the transperitoneal or the extraperitoneal,
through a loin incision.
One of the most troublesome post-operative effects of drainage in acute
pancreatitis is the formation of sinuses. Irritation of the skin over which
the discharge flows may be avoided by protecting the skin with a bland oint-
ment. In order to limit the activity of the pancreas, a strict anti-diabetic
diet is found useful in promoting healing.
It is difficult to make a differential diagnosis in acute pancreatitis with
any degree of certainty, because there are several other violent acute condi-
tions which are so similar in their symptoms that they can probably never
be positively excluded. The conditions most likely to be confounded are, ( 1 )
perforation of the posterior wall of the pyloric end of the stomach; (2)
perforation or gangrene of the gall-bladder or duodenum.
Cases of severe acute pancreatitis have been diagnosed as acute intestinal
obstruction, renal colic, ectopic gestation, and, of course, appendicitis and
gall-stone colic.
(Ochsner) In acute pancreatitis the pain is extremely severe in the
right upper quadrant of the abdomen. There is ihtense shock ; nausea and
vomiting are usually present, and the patient gives the impression of being
on the verge of dissolution. The abdominal muscles are tense, although
Monihan found this symptom absent in some of his cases. There is usually
a history pointing to gall-stone colic in previous milder attacks.
If a tumor be felt, there is usually tympanitis on percussion over this sur-
face, because the gland is located behind the duodenum.
90 NORTH CAROLINA MEDICAL SOCIETY
Cyanosis has been observed by Opie and others. Sugar is present in the
urine in some cases. Egdahl gives a careful review of 107 cases in his study
of the symptoms and diagnosis of acute pancreatitis which is well worth the
careful consideration of the clinician.
REPORT OF CASES.
CASE. — Mr. E. W. C, aged 32, occupation civil engineer, weight 140
pounds. Entered hospitatl October 23rd, 1919. Diagnosis acute intestinal ob-
struction had been made and patient was referred for immediate operation, to
relieve the obstruction. Two years previous he had been turned down for life
insurance and one year previous for admission in the Navy, on account of
sugar in the urine. He had suffered during this time with attacks of epigas-
tric pains or colic. Two weeks previous to the attack, he had the "flu," but
did not go to bed for two or three days at the onset. Six days before com-
ing to the hospital, he was suddenly seized with severe cramp-like pains.
Thought at first that it was an attack of acute indigestion. But when vomit-
ing kept up and constipation resisted all treatment, a diagnosis of intestinal
obstruction was made and he was sent to the hospital for immediate oppera- .
tion for obstruction. While in the station at Asheville, on the way to the
Meriwether Hospital, he collapsed. When he reached the Hospital, at 7 p. m.
his temperature was 96 2-5, pulse 140, respiration 42. Last bowel movement
was on October 18th, five days previous. Vomiting had become less frequent,
but was regurgitant and of a dark brown or black appearance, but not sterco-
ral. Hiccoughing was persistent, general tympany was present, although
there was a marked localized distension of the epigastrium. The patient ex-
pressed a sense of fullness and distension. A marked cholemia was present.
Palpation was made diificult on account of the epigastric distension and great
tenderness. A deep lying tumor-like mass could be felt with some difficulty,
above the umbilicus. Urine showed large amount of sugar, small amount of
albumen, small amount of blood, numerous granular casts, Indican normal,
acetone positive, specific gravity 1030, reaction acid.
A high asafoetida enema was given and a few small particles of fecal mat-
ter and a large amount of flatus was expelled. Examination of material re-
turned showed a few fat droplets.
A diagnosis of acute pancreatitis was made, but on account of the profound
shock, no operation was attempted. Patient complained of intense thirst, a
smothering feeling, and a slight headache. He became restless, tried to get
out of bed, developed involuntary urination, expelled Murphy drip, breathing
became shallow, pulse very weak, and lived only 18 hours after he was ad-
mitted to the hospital . He vomited a laarge amount of. black coffee ground
fluid the last thirty minutes before he died.
CASE 3. — Mr. P., age 56, weight 250 pounds, well-to-do farmer. Previous
history negative except that he had suffered with light attacks of acute indi-
gestion. He was a big eater, particularly at his evening meal.
The day previous to the onset of the attack, he rode on a wagon, worked
hard all day, ate a hearty supper, and slept well during the night. Got up in
the morning feeling as well as usual, began dressing, and while stooping over
tying his shoes, he was seized with the most frightful paroxysmal pains in
the epigastrium, followed by nausea and vomiting, associated with extreme
shock.
SURGERY 91
The family physician was called and a diagnosis of acute intestinal ob-
struction was made. The pain was so severe and shock so profound, that the
physician thought he was "going out" in spite of all he could do. He was
brought to the Hospital 18 hours later. The vomiting was copious at first,
of a dark green bilious character, later a dark brown, but not stercoraceous.
Hiccough was absent.
A high S. S. enema was given after entering the Hospital, and some parti-
cles of fecal matter and gas were expelled. The patient had not voided since
the onset of the attack, and catheterization showed ten ounces of urine in the
bladder. Urine acid, specific gravity 1028, albumen positive, sugar negative,
Indican slight, many hyaline and granular casts.
Being positive that we were not dealing with intestinal obstruction, it was
decided that we had a case of acute pancreatitis. It was evident that unless
he could be reacted from the extreme condition then existing, an operation
would be a useless procedure. There was almost a total anuria during the
next twenty-four hours, in which time there developed a looseness of the
bowels, with a very offensive odor, dark green in color. Examination showed
fat in the stool. The epigastrium was very much distended. There was a
circumscribed tenderness in the region of the pancreas, extending into the
left loin, with tender spots about over the abdomen.
The pulse were frequent and irregular, and almost impercc'ptib^e. The tem-
perature, slightly elevated on admission, dropped to sub-normal, a few hours
later rising to 101. Lowest temperature 97, highest 101.
There was an extreme mental lethargy, followed by a low grade delirium.
A mild jaundice appeared in the second twenty-four hours, with bile, sugar,
and a large amount of acetone in the urine.
His condition grew steadily worse, and he passed away in a little more
than seventy-two hours from the time he entered the Hospital.
Autopsy showed some free blood stained peritoneal fluid. The gland was
enlarged, soft and succulent. It had a dark reddish-brown color. The duct
and its ramifications contained blood and icterus fluid, the gall-bladder was
distended, but no stones present. Several round, opaque areas of dissemi-
nated fat necrosis were found upon the mesentery and omentum and extra-
peritoneal fat adjunct to the pancreas. There was an acute cellular infiltra-
tion of the connective tissue of the organ, with an extensive necrosis of the
lobules. Bacterial examination was negative.
CASE 3. — Mr. W., age 52, weight 230 pounds, occupation foreman. Went
to church on Sunday morning and while on the way back home, only a short
distance from the house, he was attacked by a sudden upper abdominal pain,
overwhelming in character, accompanied by incessant vomiting, with upper
abdominal distension, weak, rapid pulse, sub-normal temperature, collapse,
and slight cyanosis. He had always been well, and this was the first time
he had ever needed to call a physician. He gave no history of previous indi-
gestion or epigastric pains. The family physician was called, tie did all in
his power to relieve the man, and after he had utterly failed to move his
bowels, check vomiting and relieve hiccoughing, he concluded he had a case
of intestinal obstruction.
The patient was placed on the train during the second twenty-four hours
and brought to the Meriwether Hospital for immediate operation for obstruc-
92 NORTH CAROLINA MEDICAL SOCIETY
tion, A high S. S. enema with 1-2 ounce tincture of asafoetida added result-
ed in a large, soft, brown, liquid stool and a quantity of flatus. The stool
contained fat droplets.
Temperature on admission was 99, pulse 124, respiration 36. Hiccough
was continuous. There was a limitation of diaphramatic movements. There
was deep seated epigastric pain, increased by firm point pressure, over the
splenic area, which extended around toward the left loin. Tympany was be-
coming general, with points of tenderness over the abdomen. The transperi-
toneal route of operation was chosen. The entire gland was enlarged and the
head of the pancreas contained a dirty green fluid. Areas of fat necrosis
was disseminated throughout the mesentery and omemtum. The pus con-
tained the bacillus coli communis.
The abscess cavity was drained in the usual manner. The hiccoughing per-
sisted. There developed a looseness of the bowels, with a very offensive odor.
The urine before operation was clear amber, specific gravity 1032, acid, al-
bumen large amount, sugar large amount, Indican medium amount, acetone
medium amount, casts, small number of Hyaline and coarsely and finely
granular. Day after operation urine down from 1032 to 1018, sugar and al-
bumen about the same, Indican negative, acetone had increased to large
amount. Cell count dropped from 21,000 to 16,000. Sugar continued to in-
crease, albumen and casts diminished. There was a large increase of sugar
and acetone on the 14th day. He died on the 16th day after the operation
and the 19th day of the attack.
Autopsy showed the gland to be swollen and the right half of head dotted
with numerous yellowish-white spots and prominences arranged indiscretely.
The left half had a dark reddish-brown appearance throughout.
Diagnosis of pancreatitis was not confirmed either by operation or autopsy
in the first case. I am of the opinion that it was a sub-acute or chronic pan-
creatitis of about two years duration, with an acute termination, probably
influenced by the recent "flu" infection.
The second case was one of acute hemorrhagic pancreatitis, with profound
shock and rapid termination.
The third was a case of suppurative pancreatitis, although there were evi-
dences of pancreatic hemorrhages. The suppuration did not necessarily pre-
cede or accompany the hemorrhages.
Osier says that intestinal obstruction or acute perforating peritonitis is
usually suspected. He reports a case admitted to the Johns-Hopkins Hospi-
tal illustrating the common mistake. The young man had symptoms of in-
testinal obstruction for three or four days. The abdomen was distended,
tender, and very painful. He says: "I saw him on admission, agreed in the
diagnosis of probable obstruction, and ordered him to be transferred to the
operating room. Halsted found no evidence of obstruction, but in the region
of the pancreas and at the root of the mesentery, there was a dense, thick,
indurate mass, and there were areas of fat-necrosis in both mesentery and
omemtum. Oddly enough, this patient returned four years later with another
attack, but he refused operation and his friends took him away."
SURGERY 93
DISCUSSION OF DR. GLEXx's PAPER
Dr. Jas. M. Parrott, Kixstox : I wish Dr. Glenn had given us some
details as to the condition of the teeth and tonsils, of the ears and sinuses,
in these cases. Perhaps he will do this when he closes the discussion.
Dr. J. W. Tankersley, Greexsboro : Dr. Glenn's paper is too inter-
esting to go by without discussion. Personally, I have never had any exper-
ience with acute pancreatitis, but I have seen several cases in operations on
the gall bladder and other abdominal organs. The question of primary in-
fection has engaged my attention, and the question is, is it a primary pan-
creatitis or is it secondary to some infection elsewhere, as Dr. Parrott sug-
gested, an infection of the teeth or sinuses, or, more important in my opin-
ion, an infection of the gall bladder or other pelvic organs. There have
been several theories advanced. It has been demonstrated that bile, if in-
jected into the head of the pancreas, will cause acute pancreatitis. Bile as
injected from the gall bladder does not cause it. Therefore, if the gall-blad-
der is not functioning we have the possibility of infection. Another source
of infection is hcemic. We all recognize that source, and I believe that to be
the only primary source of infection in the pancreas. Another source of in-
fection is the lymphatic. Frequently we run across these cases of pancrea-
titis. I say frequently — they are not frequent. If we pay more attention
to the pancreas we shall run across more cases. The cases are subacute or
chronic, and I believe in most cases they come from infection of the gall-
bladder and possibly from the appendix. I have seen cases of deaths which
came from acute pancreatitis. One was an exacerbation of a chronic condi-
tion which existed previous to a gall-bladder infection. They presented the
typical picture previous to death which Dr. Glenn set forth.
I was interested in Dr. Glenn's paper, I think it was excellent, and I
would like to hear more discussion.
Dr. Jas. M. Parrott, Kixston: We have Dr. Southgate Leigh, of
Norfolk, and other distinguished visitors with us today, and I wish to move
that the courtesies of the floor be extended to them.
This motion was adopted.
Dr. Glexn, closing the discussion: I was in hope that Dr. Leigh and
Dr. Royster would have something to say about this paper.
There are two things that impress me which I did not bring out in the
paper. One is the fact that when you have complete intestinal obstruction,
the use of the enema will always result in failure to obtain expulsion of gas.
You must be careful to see that all of the air is out of the hose going from
the syringe. Always in testing thoroughly for gas, have the stream of
water running when introduced into the rectum. Another distinct differ-
ence is in the vomiting of pancreatitis. It never becomes stercoraceous in
pancreatitis, after a while it becomes regurgitant, some times a dark brown
color. Another thing, too, most striking, is the profound shock, pain, and
collapse in acute pancreatitis.
After you have seen a few cases, you can hardly be mistaken in the diag-
nosis.
94 NORTH CAROLINA MEDICAL SOCIETY
SAVING SUPPURATING INCISIONS.
Hubert A. Royster, M. D., Raleigh, N, C.
A plan for preserving abdominal incisions, which have suppurated deeply
and preventing them from breaking down, has been employed in my hospital
services for several years. The results have been so encouraging that the
technique iS' herewith presented with confidence. Most frequently, the
method is applicable to appendiceal incisions, but it may also be used in in-
fected wounds of any kind.
The fundamental question of drainage enters at once into our consider-
ation. Some of us have come to believe in the reverse of the old motto and
when in doubt we do not drain. The perfectly frank suppurating abdo-
mens require an outlet; these admit of no doubt, and we drain them. But
the cases concerning which we are in doubt rarely ever require a drain, be-
cause the condition is mind, not convincingly infectious otherwise we would
not be in doubt. The abdomen may be closed with safety, yet there are
many good surgeons who continue to put in drains when they find murky
serum in the cavity or are confronted with gangrenous appendix even when
it is enveloped in omentum and unruptured.
There have been three steps in the advancement of surgery. Formerly
we operated to save life ; later we operated to save time. The economic side
of surgery is most important. The greatest loss of time from abdominal
operations occurs in cases that are drained, so that any method that reduces
the confinement period to a minimum is desirable.
Where drainage is needed it becomes a matter of great economic value to
use stab wounds outside of the incision rather than to place a drain through
the incisions. When this is done, in eight out of every ten cases the Avound
is kept intact and heals perfectly, while drainage is efficient and safe.
In some of the types referred to as doubtful in which the abdomen is
closed, the wound suppurates, though the abdominal cavity remains free
from infection. It is well known that the resisting power of the tissues of
the abdominal wall is not so strong as that of the peritoneum. One is not
surprised therefore when a leaky appendix is smeared over the open wound
or a tight one ruptured in lifting it out, to observe a swollen and tender
area around the incision four or five days later. As a rule the focus of this
infection is under the aponeurosis and within the fibres of the internal ob-
lique muscle. If the incision is closed loosely, suppuration is not so apt to re-
sult.
Supposing now that the wound has suppurated, as described, we will be
apprised of its occurrence by continued pain near the incision, a possible rise
of temperature, and, on inspecting the region an edematous, bulging area to
one side or the other of the incision. In the McBurney incision this swollen
area usually is seen to the outer side of the wound. (Fig. 1.) As soon as
the condition is recognized, a small spot of skin at the most prominent part
is injected with a local anesthetic and a bistoury plunged deeply downward
and inward. Through this small stab the pus is evacuated. (Fig. 2.), aid-
ed by pressure upon each side. When the small cavity is emptied a quanti-
ty (equal in amount to the pus removed) of a ten per cent melted iodoform-
vaseline ointment is introduced by means of glass syringe. (Fig. 3.) This
distends the cavitv fills the Interstices and solidifies on cooling. A cold wet
SURGERY 95
compress is immediately applied over the whole area, and an ordinary dress-
ing over this. As a rule, the wound is not disturbed for four days, when on
removing the dressing the incision and the suppurating area will be found
clean and intact. Slight pressure will cause any excess of ointment to exude
and another cold compress may be put on. If before the fourth day a dis-
charge be noted through or around the dressing, the wound again may be
emptied by pressure and a second injection of the ointment made, following
the same plan in the after-treatment as outlined above.
The only advantage of the iodoform is its odor which counteracts that of
the colon bacillus in the pus. The melted ointment method is not new with
me or possibly to others. As long as twenty years ago I used it in the treat-
ment of suppurating buboes and ischio-rectal abscesses * and have continued
to employ and recommend it ever since with the utmost satisfaction. Other
substances beside iodoform may be incorporated with the vaseline ; but hav-
ing tried many different powders I still prefer iodoform. In this type of
cases it is certainly superior to bismuth which came into vogue for other pur-
poses much later. It is admitted that simple vaseline would be sufficient in
many instances except for the absence of deodorizing qualities. Before in-
troducing the ointment the wound cavity may be washed out with Dakin's
solution or a weak dilution of hydrogen dioxide. We have not found this
to be essential.
DISCUSSION OF DR. ROYSTER's PAPER.
Dr. a. G. Brenizer, Charlotte: Practically all the men in the base
hospitals in the war had an opportunity to close a lot of wounds. Our
practice in making the secondary sutures was to disregard practically every-
thing but the gas bacillus, the streptococcus, and the tetanus bacillus. The
wounds were frequently treated with wet compresses, or letting whatever
pus formed escape through the suture holes. Without the use of Dakin's,
without any antiseptics at all, the closings were just as successful as if treated
with Dakin's. I do not believe with Dr. Royster that it is necessary to make
a stab at the side of the wound, and I do not believe the ointment helps
much. I believe that the evacuation of the pus would possibly do about as
well. I have not had experience with the ointment and I do not know
whether or not Dr. Royster ran parallel cases, but I would be surprised if
the antiseptic ointment did very much good.
Dr. T. C. Bost, Charlotte : This question of drainage is a very im-
portant one. The late war, among other things, has taught us a lesson in
not draining. The whole practice is swaying toward the non-drainage side
and I am sure it is a step in the right direction, but I think the fact remains
that when we are in doubt we should drain. It is a fact that the less experi-
enced man wall be more in doubt when to drain. The more experienced
men, of course, will be in doubt sometimes, and I think it is up to them to
drain in doubtful cases. Notwithstanding the fact that drainage, if unnec-
cessary, will produce a certain amount of harm and that in the absence of
drainage we minimize the possibility of adhesions and wnth drainage we in-
vite the possibility of external contamination, in these border-line cases I
*New York Med. Record.
96 NORTH CAROLINA MEDICAL SOCIETY
think we shall do more harm by not draining than by draining, regardless
of who treats them.
Dr. J. T. BuRRUS, High Point: I rise more to a question of personal
privilege than to discuss the paper.
In the first place, I wish to "come before you and ask Dr. Long's and Dr.
Royster's pardon for the somewhat vehement attack which I made upon a
paper of a similar nature in Durham several years ago. I think that Dr.
Long presented a paper at that time upon the question of drainage. I am
sure that he and Dr. Royster were right at that time and that they are right
now, and equally sure that I was wrong. However, I maintain this, and
that was the position which I endeavored to occupy at that time, that in the
hands of men who have had an unlimited experience — Dr. Henry Long, Dr.
Highsmith, Dr. Royster, Dr. J. W. Long, and men who have done an im-
mense amount of work — there is a difference in degree in the question of
drainage. They know when to drain and the kind of serum or exudate that
can be safely enclosed. But take the young man, who is just beginning, a
man who has not had a large experience, and perhaps the safest thing for
that man to do is to drain. So the difference would be in the degree of ex-
perience that the men have had.
I am not familiar with the method of handling wounds according to Dr.
Royster's idea. I believe that if pus or fluid accumulates in the abdominal
wall the only question is the question of drainage. I do not see why that
should not come out through the first or primary incision as well as in open-
ing up a new field. Again Dr. Royster may be right and may be a pioneer,
and if so, when this question comes up again in six or ten years, I shall be
very glad to come up and thank him for the teaching. It is very important
and I think that our greatest prerogative is not to have trouble in surgical
wounds, and I believe that we are now living in an age when we do not
have very much trouble with them — that is, when the wounds are clean pri-
marily. In the years 1917 and 1918 it was my privilege to do and to wit-
ness a large number of incisions made primarily, and when we made these
wounds and were careful with our antiseptics I do not recall a large number
of cases wherein there was an accumulation of pus or where the wall was
primarily infected.
I thank you very much.
Dr. Southgate Leigh, Norfolk, Va.: I was very much impressed
with Dr. Royster's ingenious procedure, though I have never used it. I was
rather surprised not to hear him speak of dichloramin-T, for it seems to us
that that is the very best antiseptic for promoting the healing of soiled
wounds. Our experience has been very satisfactory. I do not recall a single
case in which the wound has failed to heal when we have sprayed it thor-
oughly with dichloramin-T in five or ten per cent solution and then closed
it up with the solution in the wound. We always sponge these wounds with
bichloride, also.
I cannot agree with the doctor that when in doubt we should not drain.
I am very much afraid that is a dangerous doctrine. I expect the best plan
to follow is to imagine ourselves in the place of the patient and then decide
what we would want done. I do not believe there is a man in this room
who would want a wound closed in his own abdomen if he were in doubt,
SURGERY 97
and I think that applies to all of us — those who have had considerable ex-
perience and those who have not. Of course the reason for closing up the
wound is to save time. In suppurating appendicitis, if you will make a trans-
verse incision, cut the muscles at the other end, and spray the wound thor-
oughly with dichloramin-T, you will get a good result. There will not be
much delay in the healing on account of the small sinus.
I hope we shall hear something about dichloramin-T and about the use
of Dakin's solution, for they are wonderful helps in surgery. The war has
done that much for us. Dakin's solution, made exactly in the way advised
by Carrel and Dakin, applied practically constantly, at least every two
hours day and night, to the wounds will hasten tremendously the healing of
the wound. I believe that in suppurating appendix cases we are cutting
short the hospital time by at least two weeks by the use of Dakin's solution.
Dr. J. W. Long, Greensboro, N. C. : Dr. Royster's treatment, which
he has presented to us so clearly and forcefully, appears to be addressed to
the incision itself and not to the deeper parts. His method, which he de-
scribes in his characteristic facetious style, may be paraphased as a "super-
ficial salvage of suppurating smells." Dr. Royster merely iterates a truism
when he says that the tissues of the incision are far less able to take care of
infection than is the peritoneum.
Now, as to the merits of the method described by Dr. Royster, I wish to
say that it is a most excellent procedure. When we sew up an incision in
the presence of infection we should by all means make provision for drain-
age. Also, in case infection subsequently develops drainage must be es-
tablished either by opening the incision or by making a stab wound to the
side. I think a far better plan, is to leave the incision in such a condition
that it will drain itself, either by approximating the edges loosely or by in-
troducing drainage at the time of the operation. When we are dealing with
infected tissues such as a gangrenous appendix, it is wise to drain the incision,
whether we drain the abdomen or not. In severe infections drains should
be placed between each two layers of the abdominal wall. By doing, this we
avoid extensive suppuration of the abdominal incision.
Dr. Royster's iodoform and vaseline injection is a splendid one. It is
evidently patterned after Beck's paste and Rutherford Morrison's hip. Both
are excellent applications for suppurating wounds. However, Moynihan
says that they used bip in the English Army with excellent results, but grad-
ually quit it and got just as good results.
Dr. Royster, closing the discussion : If Dr. Brenizer will remember, I
said I claimed no superiority for the iodoform except its smell, which gave
rise to Dr. Long's text from the Scriptures. If you drain through the wound,
you will have a sinus which will stay there as long as you pack a piece of
gauze into it, and that is just as long as you want to keep the patient in bed.
I have not only developed parallel cases, but I have tried and watched other
methods, such as opening the incision itself and using hot packs or irrigation
and tapes. Usually it is three weeks before these wounds heal
In regard to Dr. Bost's question, I will leave him a beautiful little conun-
drum : "When is a drain not a drain ? When it is a stopper."
Dr. Burrus gives me a chance to say, "Whom the Lord loveth He chas-
teneth." He has seen the light. The most important attitude for a medi-
98 NORTH CAROLINA MEDICAL SOCIETY
cal man is to feel miserable today unless he knows something he did not
know yesterday.
Replying to Dr. Leigh's remarks, I have not used dichloramin-T, but
Dakin's solution and other solutions, on these wounds before closing them
up and then found that I had occasional suppuration outside the line of the
wound. The wound was all right, but the organisms penetrated the tis-
sues before we could get to them with the solution. His suggestion of using
dichloramin-T is a very favorable one, however, and I think I have in mind
what to do to save some of these wounds from suppurating.
When I said, "When in doubt, don't drain," I meant to imply that the
experienced surgeon is never in doubt in the dangerous cases. You and I pro-
bably all of us, drain the same kind of cases. But we may differ about the
cases we do not drain. Do you tell me that a man opens an abdomen and the
appendix is not ruptured, but the whole abdomen is filled with a murky
serum, that he is going to drain? If he does, it is because he is afraid of a
fetish. You do it because someone said it in a textbook or in a clinic. Now
if you have a great big gangrenous appendix wrapped up in the omentum,
are you going to drain it? I have seen men drain these types of cases of
which I have been speaking, and they kept the patients in bed a long time.
Of course if the appendix is ruptured and there is pus all over the abdomen
you will drain. My most devoted friend, the man I have patterned after
most in North Carolina, and the man who is chiefly responsible for my hav-
ing come back to the State, has expressed in an alliterative fashion what I
have tried to tell you He speaks of my method as the "superficial salvage
of suppurating smells" May I say this much — also alliteratively ? — that
smell is issuing from saprophytic sinuses considered by some to demand a
cigarette; but sound surgical sense says otherwise. Dr. Long is eternally
right about draining the incision ; but I have presented a plan for saving the
incision without draining it. The iodoform ointment accomplishes the same
thing and leaves the incision intact. The method is not fashioned after
"bipp," because I used it twenty years ago. I wish to emphasize that it is
the plan and not the material which is important ; it is economic surgery and
not surgical fear which I am trying to impress upon you today.
GOITER.
Observations drawn from 150 operated cases and 71 unoperated cases.
Addison Brenizer, M. D., Charlotte, N. C.
I am employing the word goiter in a very loose sense, to embrace all en-
largements of the thyroid gland. The word goiter, while counting a great
deal, in reality denotes little. It denotes a more or less permanent enlarge-
ment or mass over the front of the neck to the lay mind and the same to
many of the medical mind, with the exception that the enlargement has to
do with the thyroid gland., The word goiter, however, is a very familiar
word and from use, good or bad, is well accepted. Though as vague per-
haps as rheumatism in its denotative sense, still it is of value in its connative
sense, if the pathological conditions of the thyroid gland included under this
term be understood.
A scheme of the pathological anatomy of the thyroid gland is necessary in
SURGERY 99
the diagnosis and treatment of goiter and I would formulate an outline such
as the following.
A Disturbances in development : ( 1 ) Absence of the thyroid gland.
(2) Accessory thyroids, from the base of the tongue (foramen cecum) to
the sight of the normal gland, along the tract corresponding to a thyroglos-
sal duct and beneath the sternum and upper chest.
B. Disturbances in metabolism: (1) Atrophies, after inflammations
and reductions of blood supply on tying off vessels. (2) Degenerations:
Parenchymatous, hyaline, amyloid, calcarious.
C. Disturbances in circulation : ( 1 ) local and general venous conges-
tions may lead to enlargements of the thyroid. The transitory swellings
during menstruation, initial sexual excitement and pregnancy are caused by
a congestive hyperaemia, with increase of a watery colloid. Under this
heading come the false goiters of adolescence and pregnancy. (2) A mark-
ed development of either arteries or veins may accompany any of the goiters
and determine the nomenclature "vascular goiter."
D. Inflammations: (1) Simple thyroiditis, characterized by degenera-
tion of epithelium and cellular excrudation, not infrequently accompanies
the various infectious diseases. (2) Visible purulent mfections are rare.
These may spread directly from open wounds or contact with the larnyx or
trachea or they may be hematogenous infection during, for example, typhoid
or a pyemia. Abscesses may break outwardly or inwardly into the trachea.
Diffuse inflammations may be followed by a destruction of glandular sub-
stances and fibrous atrophy. Goiters are far more prone to inflame and
break down than the normal thyroid. (3) Tubercles are found in the
thyroid accompaning disseminated miliary tuberculosis. Larger solitary or
multiple tubercles are occasionally observed. (4) Gummata are found
very seldom.
E. Regenerations: Thyroid tissue is slow to regenerate. Those devel-
opments of reses left after operations have likely a goitrous base. The tend-
ency of these is to degenerate.
F. Hypertrophic enlargements: (1) These are the so called goiters
proper, although the circumscribed forms offer no sharp differentiatior from
tumor growths. These hypertrophies are (a) diffuse, where the enlarge-
ment involves the whole gland or the greater part of it, and (b) nodular,
where the enlargement is issolated and encapsulated. According as the in-
crease in volume is due to accumulation of colloid substance in the follicles
of the gland or to an increase of the follicles themselves, we speak of: (a)
a colloid goiter, and (b) a parenchymatos goiter. The former type is by far
the more frequent. The goiter accompanying the symptoms complex, known
as Graves' disease or exopthalmic goiter, is usually a diffuse goiter of the
parenchymatos type, differing, however, from the parenchymatos goiter in
that the process of change in the existing follicles is more active. The folli-
cles show the lining cells changed from cuboidal to columnar forms and sup-
erimposed in several layers. The follicles empty of colloid, and the cells
often form festoons into the empty spaces. These invaginations are follow-
ed up into the follicles by the surrounding connective tissue. The intersti-
tial tissue is very vascular and permeated with leucocytes. The picture has
100 NORTH CAROLINA MEDICAL SOCIETY
been compared to that of a lactating breast and it does show every sign of
over active tissue. This process 'of change is described as hypertrophy and
hyperplasia. These changes may take place only in certain parts of the gland
and may spring up in old standing simple goiters giving rise to symptoms of
thyro-toxicosis.
G. Tumors : ( 1 ) The commonest benign tumor of the thyroid gland is
an adenoma. This tumor is responsible for many cases of nodular goiter
and is sometimes accompanied by a thyro-toxicosis, showing many of the
symptoms of Graves' disease; exophthalmos is usually absent. (2) There
are a number of varities of malignant tumors of the thyroid, interesting to
the pathologist, but impossible to differentiate clinically. The commonest
malignant tumor is a carcinoma of the adenomatous type.
Cases in my series illustrating the above pathological scheme :
A. Thyro-glossal duct — (operated.)
B. Case of Vincent's angina, cervical adenitis, swelling and tenderness of
the thyroid gland; rapid heart beat, marked exopthalmos; subsidence of the
thyroid, recession of the eyeballs, marked ptosis — thyroiditis, hyperthyroid-
ism, injury of the cervical sympathetic. 1.
(2) Old standing goiters of enormous size showing all forms of degen-
eration, even masses of calcarious deposit like bone. 37.
C. ( 1 ) Enlargement of the thyroid in young girls between thirteen and
twenty years, increase in size during menstruation usually dysmenorrhoea ;
cystic ovaries in live years ; same type of enlargement of glands during preg-
nancy. (55.)
(2) Enlargement of the thyroid in a woman forty years old; gland at
times, especially during periods, twice the size ordinarily, tense, a distinct
bruit heard over it — vascular goiter. 1.
D. ( 1 ) Accompanying flu, hard tender swelling of the right lobe of
the thyroid gland, hoarseness; after several days swelling softer; right lobe
exposed and incised, free pus — abscess of thyroid gland. 1.
(2) During subacute state of laryngitis and bronchitis, swelling of thy-
roid, becoming quite large, tender and fluctuating ; advised exposure and in-
cision, refused; abscess ruptured into trachea, patient coughed up deluge of
pus, complete recovery — abscess of thyroid gland. 1.
Goiter with additional swelling, pain and tenderness; exposure of struma
and incision, abundant pus — abscess of struma . 3.
Adenitis tuberculosa, mass corresponding with right lobe and isthmus of
thyroid! thyroidectomy, conglomerate tubercles — tubercle of thyroid. 1.
A large lymph glands in the neck, mucous patches in the mouth, macular
rash over the body, positive Wassermann; enlarged thyroid, pulse rate 120;
anti-syphilitic treatment, with disappearance of thyroid enlargement and re-
duction of pulse — thyroiditis syphilitica. 1.
Enlarged thyroid, fast pulse, 128, exopthalmos; osteo-mylitis of tibia and
cranial valut, positive Wassermann; anti-syphilitic treatment with disap-
pearance of all symptoms — thyroiditis syphilitica, hyperthyroidism. 1.
SURGERY 101
E. Right lobe of thyroid removed for exopthalmic goiter, reappearance
of struma of left lobe and isthmus, severe Graves' disease ; isthmus and part
of left lobe removed — further development on goitrous base. 1.
F. Diffuse goiter, parenchymatous and colloid. 14.
Nodular goiter, colloid. 39.
Diffuse nodular goiters, showing more or less marked symptoms of Graves*
disease. 88.
G. Adenoma, incapsulated, symptoms of thyro-toxicosis. 3.
Carcinoma, adenomatous type. 2.
Without plunging hopelessly beyond my depths into the subjects of re-
ciprocal glandular actions or humoral correlations and humoral interrela-
tions, I shall offer merely several observations which point to the fact of an
uncommonly intimate pathological correlation or interrelation of the several
ductless glands and which are well adapted for the complication of clinical
pictures.
Most of the ductless glands come into play with the thyroid ; the pituri-
tary, the parathyroids, the thymus, the adrenals, (including the medulary
portion and the entire chromaffin system,) the pancreas and the gonads.
Thyroid gland: (1) Over-function and possibly dys-function causes
Graves disease. (The thyfnus is now thought to play an important role in
exophthalmic goiter.) (2) Underf unction or absence of function in adults
produces myxedema; in infancy cretinism- (3) Total removal brings on
cachexia strumapriva, resembling myxedema. (4) Thyroid extracts im-
prove cretinism and relieve myxedema as long as it is given ; it accentuates
hyper- thyroidism.
Pituitary gland : (1) Over-function causes acromegaly. (2) Under-
function causes hypophysial dystrophy.
Parathyroid glandules : ( 1 ) Over-function is said to cause osteomalacia
and eclampsia; proof wanting. (2) Under-f unction produces tetany in
pregnancy. (3) Partial parathyroidectomy may be followed by tetany;
total removal is followed by tetany and death. Parathyroid extract and
transplantation of parathyroids is claimed to ameliorate tetany s\'mptoms, at
least temporarily.
Thymus gland: (1) Over-function may have to do with status thymi-
cus and status thymo-lymphaticus. (2) Under-f unction ; the gland nor-
mally involutes between the tenth and fifteenth years. (3) Thymectony
has no influence on otherwise normal adults ; it has a transient retardation
of body growth in infancy ; in some cases of exophthalmic goiter it has a
checking influence on the progress of the disease. (4) Thymus extracts
are questionable, probably accentuate an existing hyperthyroidism.
Adrenal glands: (1) Over-function causes hypertonia, hyperglycema,
glycosuria. (2) Under-function causes Addison's disease.
The pancreas: Under-function or absence of function causes diabetes
mellitus.
The gonads: (1) Over-function causes temporary excessive develop-
ment of the organism, chlorosis in females. (2) Under-function and ab-
sence of function causes eunuchoidism.
102 NORTH CAROLINA MEDICAL SOCIETY
The pineal gland : Under-function causes premature developments, es-
pecially of the genitalia.
Gley and others observed an enlargement of the pituitary glands after ex-
tirpation of the thyroid in young animals. The enlargement affects the
glandular anterior lobe ; vacuoles are found in the cells. Conversely after ex-
tirpation of a part of an adenoma of the pituitary in acromegaly an enlarge-
ment of the thyroid was observed. The hypophysis has been occasionally
found enlarged in myxedema; in such cases the enlargement may depend on
strumous degeneration. On the other hand, Benda states that the glandular
hypophysis is small in Graves disease. The statements, however, as to the
physiological correlation between the two ductless glands do not agree. But
of greater clinical interest are the pathological correlations between the pit-
uitary and the thyroid.
Thus, in endemic cretinism, not only the thyroid alone, but also the hyo-
physis is usually strumously degenerated. Josefson reports a case of hyper-
plasia of the hypohysis in congenital struma of the thyroid gland. Rosen-
haupt reports a case of sarcoma of the anterior lobe of the hypophysis in
which there was also a similar tumor of the thyroid gland. Falta has point-
ed out frequent manifestations of hyperthyrosis in acromegaly, especially in
the later stages, with corresponding pathalogico-anatomical alterations in the
thyroid gland. In multiple ductless glandular «celerosis the sclerotic pro-
cess affects almost regularly the thyroid and the hypophysis. A slight degree
of thyroid insufficiency does not seem to be rare in hypophysial dystrophy, at
least a mj^xedemoid puffiness of the face may be observed, especially in the
later stages. Finally there is evidence that the hypophysis may degenerate
in the later stages of Graves' disease, because in such cases are found char-
acteristic fat deposits and swellings of the skin that remind one of myxedema
while the hyperthyrosis still continues and shows a great sensitiveness to thy-
roidine and adrenaline.
An important diagnostic test of exopthalmic goiter is the adrenaline test
as carried out by Goetsch. This test is dependent upon whether or not ad-
renaline increases the blood pressure and pulse rate above ten points. It is
a known fact that cases of exopthalmic goiter bear adrenaline poorly and
there are many symptoms of exopthalmic goiter that point to an already in-
crease of adrenaline in the blood.
The case of Bortz and Thurmin of a girl seventeen years old who first
developed normally, the menses ceased and there developed a luxuriant deep
black beard, and a sparse mustache, hairs developed on the chest and linea-
alba. Death occurred as the result of an intercurrent illness. An autopsy
revealed atrophy of the ovaries, enormous enlargement of the thyroid, nor-
mal hypophysis ; on both sides there existed a super renal tumor rich in blood
vessels that had apparently developed from the cortex (hypernephroma.)
R. Mueller in mentioning the secondary sexual characters in which an im-
mediate dependence upon the sexual glands is shown, lists the skeleton, the
muscular system, the skin appendages, such as combs, horns, beard, etc., gives
the swelling of the thyroid gland a prominent place.
Well known is the swelling of the thyroid gland in the premenstrual per-
iod, the struma ante-menstrualis, as pointed out by Heidenhain. The sup-
rarenal cortex and the hypophysis also increase in size before rut and the
SURGERY 103
premenstrual period. The mammary glands often swell slightly and may
rarely, even in virgins, secrete colostrum. The nipples show an increased
erectibilit>' and are painful. All these changes occur as well during preg-
nancy.
It has been known since antiquity there has been an increase in volume of
the thyroid gland during pregnancy.
Falta reported a case of castration in a man for tuberculosis, where among
other symptoms a goiter developed which later receded.
Usually in castrates and eunuchoidism the thyroid gland is of less volume.
Rapid improvements in eunuchoidism have been reported after treatment
with thyroid extracts. Apert mentions a case complicated with cryptorchid-
ism in which after one years' treatment with thyroid extract, the penis had
distinctly grown, the testicles had lowered, and the weight had increased
fifty pounds. Also Parhan and Mihailesko report a similar case in a four-
teen j^ear old youth with left sided inguinal cryptorchidism and obesity ; un-
der thyroid. extract the genitals took on a rapid development.
Handmann found the thyroid glaftd enlarged twenty-four times in forty-
four casaes of chlorosis, three times with distinct Graves' symptoms.
O. Marburg reported a case of a girl nine years old, who during eight
months' time became obese, excessive especially on the breasts and abdomen.
Autopsy showed a complex tumor of the pineal gland consisting of tissue of
the pineal gland, the ependyma, the choroid plexus, and of glia, there was
a colloid ctruma of the thyroid. In another case Neuman, occuring later in
life, there was a persistent thymus and the formation of a goiter.
There are a number of suggestive points in the relation of the genital and
sexual organs and the thyroid glands. In the king crab the thyroid opens di-
rectly into the uterus. The false goiters of adolescence and pregnancy are
suggestive. Cases with so called goiters of adolescence usually menstruate
late ; I have found in eight cases out of fifty-five cystic ovaries ; three of my
cases of exopthalmic goiter had already been operated on for large ovarian
cysts and one case operated on for exopthalmic goiter was later operated
for an enormous cyst. Lampe, using the Abderhalden reaction, found in the
sera of exopthalmic goiter patients, ferments against the ovaries, thyroid
and thymus. This fact would point to some defect in ovarian secretion. I
take it that the thyroid is stimulated to over-activity or reciprocally compen-
sates an under-activity of the ovaries during the developmenal period and
pregnancy.
These so-called goiters of adolescense amounting to nothing more patho-
logically than an enlargement of the gland, with increased watery colloid,
represent a hypothyroidism while reciprocating the ovaries and usually dis-
appear with maturity. Accompaning their disappearance there is usually
relief of dysmenorrhoea and extreme general nervousness during the men-
trual period.
In long standing cases of exopthalmic goiter there is occasional atrophy of
the entire genitalia and of even the breasts. I have never seen a well devel-
oped, long standing case give birth to a child. Some one has said that a test
of pure exopthalmic goiter is the fact that the woman could bear a child.
(Halsted.)
104 NORTH CAROLINA MEDICAL SOCIETY
So far as I have been able to ascertain, and this point is a difficult one to
find out, I should say that the majority of early cases of exopthalmic goiter
and the cases of goiters of adolescents were more hyper-sexual than hypo-
sexual. Thomas says: "Nearly every married woman with whom I have
discussed the matter has admitted some sort of incompatibility with her hus-
band and since it almost always appears during the active sexual life, I
strongly suspect a distinct relationship." On the other hand, I believe long-
standing and out-spoken cases of expothalmic goiter to be hypo-sexual.
Briefly, the presence of a goiter is diagnosed by these simple signs: (1)
An enlargement over the front of the neck, more often asymetrical than
symetrical and of an extremely variable volume. (2) The covering skin is
normal and does not ordinarily adhere to the growth. The superficial veins
are usually considerably dilated. (3) The mass is movable in the depth,
freely from side to side, but slightly from above downward. It moves up
and down with the trachea on swallowing. (4) The consistence of the
mass varies with its anatomical structure. Except in cancer, the surface is
regularly smooth or smooth and thrown into bosses and the consistence soft
elastic; cysts are fluctuating. (5) Respiratory troubles, such as dysponea,
hoarseness, and aphonia, due to interference with the trachea and the recur-
rent laryngeal nerve. (6) Dysphagia, from compression of the esophagus.
(7) Cyanosis, from pressure on veins. The internal jugular vein and car-
atoid artery are pushed outward and backward and are very rarely troubled.
Indications for operation: (1) Cosmetic. (2) Relief of pressure on
trachea, esophagus, nerves and blood vessels. (3) Relief of hyperthyroid-
ism and thyrotoxicosis, noted in twenty to twenty-five percent of simple
goiters. (4) Prophylaxis for the preceding.
Dangers of thyroidectomy : ( More on paper than in reality ) . ( 1 ) Anes-
thesia. (2) Hemorrhage. (3) Shock. (4) Infection. (5) Recur-
rent laryngeal nerve injury. (6) Injury to parathyroid glandules. (7)
Air embolism. (8) Incision of trachea or collapse of trachea.
In fact that most of the large goiters are enucleated from the gland itself
and the gland left behind protecting the deeper structures of the neck, and
even in thyroidectomy the posterior capsule and a shaving of the gland are
left behind, eliminates most of the dangers enumerated above.
Symptoms of Graves disease :
A. Major symptoms: (1) Tachycardia. (2) Exopthalmos. (3)
Goiter.
B. Minor symptoms: (1) Tremor. (2) Muscular weakness. (3)
Nervous excitability. (4) Mental depression. (5) Vertigo. (6) Eye
signs, a dissociation between movements of the eye balls and upper lids (von
Graefe) ; b — widening of lid slits (Dalrymple) ; c— protrusion of eye balls;
d — insufficiency of convergence (Moebius) ; infrequency and incompleteness
in winking (Stelwag). (7) -Paroxysmal dyspnoea (Bryson), asthma. (8)
Intermittent sweating, diarrhea or vomiting. (9) Gravity of the disease
increased by mental and physical exhaustion; by thyroid extract and to a
less extent by iodine (therapeutic test), by adrenaline (Goetsch's test).
(10) Emaciation and anemia. (11) Leucopenia, with increased lympho-
cytosis. (12) Oedema of lids, later of feet. (13) Discoloration of skin,
pigmentation, urticaria.
SURGERY
105
There is the closest analogy between the syndrome of Graves' disease and
the eifort syndrome. In France I was able to observe practically all transi-
tions between a mild effort syndrome and well marked cases of Graves dis-
ease.
Indications for operation : ( 1 ) In all out-spoken cases of Graves' dis-
ease of at least one year's duration. (2) In all milder cases after the fail-
ure of medical treatment.
Surgical procedures: (1) Application of cold to the thyroid gland. (2)
X-ray and radium exposures over the thyroid and enlarged thymus — danger
of injury to the parathyroids and tetany. (3) Injections of boiling water
into small areas of the gland (Porter). (4) Ligation of thyroid vessels
(temporary and transient relief). (5) Thyroidectomy, partial, except in
malignant disease. (6) Thymectomy in Graves' disease. (7) Trans-
plantation of parathyroids (Halsted).
Series of cases:
Operated 150
Not operated 71
Operations
Enucleation of nodular goiters (colloid) 39
Enucleation of adenoma (thyro-toxicosis) 3
Exposure, incision, and drainage (abscess) 2
Excision of conglomerate tubercles l 1
Ligation of superior thyroid vessels 2
Thyhoidectomy-partial (simple goiter, thyro-toxicosis 16
Thyroidectomy, lobe and isthmus (Graves disease) 83
Thyroidectomy, total (adeno-carcinoma) 2
. 150
Clinical cases:
Cases too mild or too severe for surgery 16
Goiters of adolescence 52
Goiters of pregnancy 3
71
Total cases 221
Deaths in first 28 cases 4
Deaths in 108 cases
Deaths in last 12 cases 2
The markedl}' reduced mortality has come about, not so much through an
improved dexterity and speed in operating as in better judgment in selecting
and preparing the cases for operation.
A case of exopthalmic goiter is not cured by operation alone and if not
followed up and lociked after and prohibited the resumption of former noxi,
will cure with difficulty and may even relapse.
For a successful outcome with an exopthalmic goiter patient, it cannot be
over-stressed that the patient be clearly understood before the operation,
106 NORTH CAROLINA MEDICAL SOCIETY
carefully prepared under rest, with an ice bag on the throat and heart, and
cold bathing done under the quietest and gentlest conditions. The time
chosen for operation should be when the patient is at her best possible and
not worst possible. It should be explained to the patient herself that the
operation alone will not cure, but that she can expect great benefit, if not
a cure, if after the operation she observe certain strict rules, principally rest,
mental and physical, avoiding excitement of all kinds, and the adoption of a
very simple life, free from cares and burdens.
Two of my four deaths were from exhaustion due to prolonged operation
with hemorrhage and shock. I feel that I should be able to save these two
cases at present. The other two deaths were due to an increased hyperthy-
roidism and consequent thyrotoxicosis, and w^ere likely unavoidable, certainly
at that time. During five hours' time,, following the operation on one case,
the pulse rate increased to beyond a possible count, the temperature rose to
107 degrees and the patient died under what was no far different from the
symptoms of an acidosis.
Crile recently claims that there is ten per cent increase of metrabolism for
each degree of temperature, and conversely, ten per cent decrease in meta-
bolism for each degree of reduction of temperature. He says, therefore,
that he has reduced the metabolism from toxicosis by reducing the tempera-
ture by ice packs, ice on a rubber sheet fanned by an electric fan. I, how-
ever, doubt that temperature alone can be used as a guide of metabolism, and
certainly not of metabolism in hyperthyroidism and thyrotoxicosis, because,
the most marked cases of hyperthyroidism frequently show little or no hyper-
thermia. These deaths may be due to exhaustion of the vasomotor center
through the thyrotoxicosis, with a concomitant effect on the heat center.
These deaths may be due likewise, in part at least, to a lymphatism. It
is known that, occasion is given for temporary or a permanent lymphatism
by affections of the ductless glands. The characteristic blood picture of both
status lymphaticus and hyperthyroidism is a relative increase of the meno-
nuclear elements, a relative or absolute reduction of the neutrophilic leu-
cocytes and eventually a hypereosinophilia.
According to Wiesel and Hedinger there is regularly associated with the
characteristic symptoms of status lymphaticus a lessened development of the
chromaffine tissue. The medullary substance of the suprarenals is essenti-
ally lessened and also the paraganglia are ill developed.
It is possible that the giving off of the mononuclear cells of the blood is
increased by hyperplasia of the lymphatic apparatus, and, on the other hand,
we must assume an enormous trophic influence is exerted on the production
of the neuthophilic elements of the bone marrow, this influence proceding
from the chromafiine tissue by mediation of the sympathetic. It is very pos-
sible that a like anomaly of constitution is the cause of sudden death in hy-
perthyroidism as w^ell as in status lymphaticus. Thus, if the chromafiine
tissue is lessened and not capable of a great functional breadth, it may, if
especial demands are made on it, as by the effects of a narcosis or operation,
suddenly give out. Such individuals either with status lymphaticus or hy-
perthyroidism, as Eppinger and Hess mention, not rarely show symptoms of
relatively increased vagal tonus, such as inclinations to sweats and anomalies
of pulse and respiration. The slight functional breadth of the chromafiine
SURGERY 107
tissues is especially important for the fate of such individuals. On the other
hand, it must be kept in mind that mononucleosis is a symptom with many
m_eanings and in itself speaks little for the diagnosis of status lymphaticus
and much less for the diagnosis of hyperthyroidism.
It is certainly true that in the preparation for operation of cases of hyper-
thyroidism that the application of cold locally and cold bathing have a very
appreciable effect in quieting the patient and reducing the pulse rate. It is
to be hoped that Crile's idea is correct and that Crile's ice packs may aid in
warding off death in these occasional cases of markedly increased hyperthy-
roidism and thyrotoxicosis following operation. For if these cases can be
protected in this way, thyroid surgery, so far as loss of life is concerned, is
made as safe as the common run of operations.
DISCUSSION OF DR. BERNIZER^S PAPER
Dr. J. B. Cranmer, Wilmington : I should like to ask Dr. Brenizer
what he thinks of the medical treatment of goiter, the Forchheimer treat-
ment, — quinine and ergotol, and in what kind of cases this may be used ?
Dr. Bernizer: In preparing cases- for operation they go through almost
the Forchheimer treatment. They are given five grains of quinine three
times a day ; and an ice bag is placed on the throat. They may get better,
but they do not hold the betterment. These cases are chronic. A few cases
respond to medical treatment, but I doubt if there is any real medical treat-
ment outside of rest or an icebag on the throat. I do not believe the thyroid
gland is the whole story, but only a part of the chain which has to be broken
by the removal of the thyroid gland. Remember, when you are treating
cases by the medical method your mortality is about sixteen per cent, while
the surgical mortality is about three per cent. Therefore, by subjecting
these cases to surgery you might save thirteen per cent. While the cures are
likely not over seventy per cent, the cures in medicine are not over thirty
per cent. I am speaking now of Graves' disease. Mild cases might respond
to the rest cure, but it is mighty hard to subject the patient to sufficient rest
cure to do much good.
Dr. Cranmer: Personally, I am of the opinion that this is a surgical
disease, but I wished to have Dr. Brenizer's opinion in the matter.
INGUINAL HERNIA.
Dr. J. T. BuRRUs, High Point
The inguinal region is one of interest to the surgeon because of the fre-
quency of hernia and the necessity for its radical cure. The writer wishes
to report two hundred operations for the radical cure of inguinal hernia.
The anatomy with which we are most concerned lies within the Hessel-
back triangle, which is bounded internally by the rectus abdominus muscles,
externally by the deep epigastric artery and inferiorly by puparts ligament.
The ilio-inguinal nerve lies directly under the fascia of the external ob-
lique. Care must be exercised that this nerve is not divided or traumertized.
This nerve has much to do with vitalizing the tissue with which we are con-
cerned. The test of any operation for hernia is that the parts will be secure-
ly held and that the opening will be permanently closed in a way that no
other^ tissue will be destroyed and that the patient will be able to comforta-
bly discharge his duties unhampered.
108 NORTH CAROLINA MEDICAL SOCIETY
In umbilical and incisional hernia, openings that can be totally obliterated
all are doing an imbrication operation, thus building a firm and secure wall,
and in many cases a wall more secure than nature constructed in the first
place.
In operating inguinal hernia the question of the spermatic cord has been
uppermost in the minds of the surgeons. Many have written often and at
length on transplanting the cord ; another list has condemned this, adhering
to Macewin's idea — not to transplant the cord, but to place it in the notch
as securely as possible, obliterating the canal with the conjoined tendon and
puparts ligament anterior to the cord and plugging the opening in the inter-
nal ring with the sack.
Again, a good deal has been said about the amount of pressure that could
be placed on or around the cord without injury to the testicle, a goodly num-
ber doing the Bessini operation, bringing the tissue about the cord as closely
as possible. Others doing the same operation seem to have no concern as to
how loosely the cord lies in its new canal.
In the summer of 1917 the writer was assigned chief of surgical service in
a United States Army Base Hospital. In the early fall of this year an op-
portunity was presented to observe a large number of men who, as j'ou know,
went into service with hernia. In the early fall these men became unfit for
duty owing to the combat drills and other tests of physical fitness. A real
opportunity to try out the different operations for the cure of this condition
presented itself. '
The first ten cases were operated according to Bessini operation ; eight
cases were operated according to Macewin method; eleven cases after the
Furgerson method. These cases were kept in bed twenty-one days, then al-
lowed to walk some each day in the wards, gradually increasing their exer-
cise and retained in the hospital six weeks. At the end of this time they were
returned to duty. The day following their arrival with their organization,
full duty was assigned them and the test given was the ability to withstand
as much as the man that had been hard at it every day.
Two (2) Bessini cases returned, two (2) Macewin cases returned, one
( 1 ) Furgerson case returned to hospital with a recurrence of hernia. This
(a very large percentage of recurrences) was not satisfactory to the chief of
the service. The idea was to build a wall as securely as possible, through
which the cord could emerge without injury to the testicle and at the same
time hold. The writer began the following method, and, so far as I know,
no recurrences were reported.
At first the tissues were not sutured as closely about the cord as later, the
cases being later observed closely to see that the testicle was net injured.
Operation: (Fig. 1) Incision Sj/z to 4 inches long parallel with and two
inches above puparts ligament, skin superficial and deep fascia divided. The
fascia was dissected from external oblique, exposing a very broad field, 35^
to 5 inch incision through external oblique at the dividing fibres. Here it is
necessary to lift up the fascia exposing the ilio inguinal nerve, care being
taken not to injure the nerve. Fibres of external oblique divided the length
of skin incision. The outer layers of external oblique picked up with hema-
stats and sharp dissection to bottom of puparts ligament. Two hemastats
placed on internal fibres of the divided external oblique. By sharp dissec-
Fig. 1
Fig. 2
Fig. 3
Fig. 4
/
r^
/
- L
" ' ''^"\
Fig. 5
Fig. 6
Fig. 7
>
'^- t;:
wi
Fig. 8
Fig. 9
Fig. 10
SURGERY 109
tion this flap was carried free internal to the conjoined tendon. This ex-
poses the canal in its entire length with the cord and its coverings. (Fig.
2) The cord lifted from canal b}' blunt dissection is freed. A tape is passed
under cord for the purpose of easily lifting the cord to either side. The
coverings of cord are divided, sack located and lifted free from vas and cord
dissecting it free to internal ring. (Fig. 3) The sack opened and a through
and through suture passed through sack, which is ligated as high up as pos-
sible. The sack is now cut, which allows the stump to recede in the abdom-
inal cavity. (Fig. 4) The cord held external until the lower sutures are
placed. (Sutures used Chromic Gut No. 3). The internal flap or the
divided external oblique is lifted up, exposing the conjoined tendon. From
the under surface of the sheath the suture is carried around a goodly bundle
of this fascia, the conjoined tendon thence to the bottom of puparts ligament,
grasping the ligament w^hich is now pleated on itself. (Fig. 5) The sutures
are placed in this way until the internal ring is reached, usually requiring
four of five sutures. These sutures are now tied, which brings the cord
from the internal ring at right angles. (Fig. 6) The internal flap is now
brought external to the first row of sutures and sutured to puparts exter-
nally and the fascia lata thus overlapping the first line of sutures. This
builds a pillow under the cord and obliterates the canal above the internal
ring or the cord. (Fig. 7) The internal layers of the external oblique are
placed under the external flap and sutured with interrupted cat-gut sutures.
(Fig. 8) The external flap is now placed over this line of sutures and se-
curely sutured over the internal flap. These sutures are placed very close
to the cord. (Fig. 9) The deep fascia closed over the cord, which has been
transplanted directly under deep superficial fascia and skin. (Fig. 10) Skin
incision closed with silk-worm gut sutures.
I now present the lantern slides that will show you the steps in the oper-
ation.
1. Skin incision.
2. Incision and dissection of facia of external oblique.
3. Separation of sack.
4. Position of first line of sutures below cord.
5. Position of sutures of overlapping flap.
6. Position of sutures in flaps above cord.
7. Conjoined suturing of flaps and position of cord.
8. Sutures line over cord.
9. Operation completed. '
SOME PROBLEMS MET WITH IN GALL-BLADDER
SURGERY.
Dr. J. W. Tankersley, Wilmington, N. C.
In reviewing 15 years' experience with gall-bladder operations and fol-
lowing their ultimate outcome I have been struck by the number of compli-
cations and difficulties so frequently encountered. Mayo in 4,000 operations
on the gall-bladder says he has encountered complications in two-thirds of
his cases. This has led to a closer anatomical study of the gall-bladder and
it is quite frequent that variations from the normal are noted. In the first
place the gall-bladder is described as a pear-shaped organ lying in the fossa
vesicalis. This is partly true of normal gall-bladders but in practically every
110 NORTH CAROLINA MEDICAL SOCIETY
pathological gall-bladder there is quite a depression, amounting in most cases
to a distinct pouch, at the under surface of the bladder just before it termi-
nates in the cystic duct. This is a frequent source or receptacle for a large
embedded stone and frequently presents an added difficulty in freeing and
clamping the cystic duct in cholesystectomy. Again anomolies in develop-
ment and formation of the cystic, hepatic and common ducts are frequently
found. The hepatics may join much lower down than normal, I have found
in one case the cystic entering into the right hepatic, the right and left hep-
atic joining just below the entrance of the cystic. Again the cystic may be
long and pass over the hepatic or around it before joining to form the com-
mon. You can readily see the importance of understanding the possible
conditions to be met with in ligating the cystic duct as a mistake in ligating
here cannot be easily rectified.
In an enlarged empyemic gall-bladder with adhesions to the pylorus duo-
denum and transverse colon the typical splitting of peritoneum, grasping of
duct and artery separately, is attended with much care and difficulty. In ad-
dition if we should have duct obstruction with its comcomitant jaundice the
difficulties are at once magnified by the slow but aggravating oozing of
blood due to the delayed coagulation time and possibly heamic changes. To
correct or lessen this oozing I have been in the habit of injecting blood ser-
um intravenously preliminary to operation in all cases of jaundice. Another
possible source of hemorrhage is from slipping of a ligature on the cystic
duct or injury to the portal vein. On three occasions, I have seen distress-
ing hemorrhage, twice from injury to the portal circulation, and once from
ligature slipping on the cystic artery. Of course, we would only look for
this in those cases of extensive inflammatory conditions, where dissection is
difficult. These difficulties have to be avoided by double tying and more
careful freeing of the duct and artery before ligating. In my mind the next
most frequent difficulty is in removing stones from the ducts. I believe there
is a frequent recurrence of trouble post-operative due to a failure to properly
palpate and remove stones. We are told to pass a probe through the gall-
bladder or divided end of the cystic duct and so on down the duodenum.
Personally this has never been an easy matter to me and I have frequently
noticed others stop after a vain attempt and remark that there were no
stones in it anyway. To successfully palpate and detect small stones is not
so easy when we consider the number of hardened, inflamed glands at the
junction and along the duct that might be mistaken for stones and the
infiltrated condition of the ducts themselves. Occasionally we find the duct
obstructed with a stone too large to work back but there are extremely few
cases where I have had to open the duct to relieve the obstruction. If stones
large enough to go through the duct and obstruct the intestines surely we
should be able to get them out without cutting the duct. Such cases have
been reported. I believe most cases of stone obstruction occurs at the junc-
tion of the cystic and hepatic or in the diverticulum of Vater. Where the
obstruction occurs high up it is the exception that you cannot milk it back
into the divided ends or opened gall-bladder, or if it occurs in the lower end
open through the duodenum and deliver the stone by divulsion of the orifice,
closing the duodenum afterwards. This gives a good drainage as nature
intended it, via naturalis. This method was suggested to me by my friend
and teacher. Dr. J. W. Long, several years ago and I have found it very
SURGERY 111
satisfactory. Critics may argue here that there is more opportunity of in-
juring the pancreatic duct or allowing bile and infected material to enter the
duct. Personally I have never had this trouble and will leave that discussion
to any that have had more experience with this method than I. The prob-
lem of pancreatitis complicating gall-bladder disease, I believe is too fre-
quently overlooked but that is in the nature of a complication. However,
I wish to add that the only two deaths I have encountered in the last four
years in gall-bladder surgery were due to this complication. Next to diffi-
culty in removing stones is injury to the ducts. Of course, this would occur
only after removal of the bladder. It is very easy to say deliver the gall-
bladder into the wound by traction, separate the peritoneum, grasp the duct
with forceps, but in those large inflammatory conditions this is easier said
than done and with much experience in gall-bladder surgery any of us will
acknowledge how easy it is in this condition to grasp, cut or stitch the hepa-
tic or common duct during this operation. I know of no more tedious or un-
satisfactory operation than repairing an injured or severed common duct
weeks or months afterward. Should this cut be recognized at once it may
be properly repaired over a small rubber tube or if not completely severed
rubber tube inserted and allow^ed to close spontaneously. This difficulty is
well illustrated in the following case :
Mrs. C. H. S., married, several children, had suffered for years with
symptoms indicating gall-bladder trouble and was operated on several
months previously. Entered the hospital in April, 1919, intensely jaundiced.
Had been jaundiced about two months, gradually growing more intense.
Blood examination negative, urine almost black with bile. Patient still able
to be up and about the house but slowly going down hill. We thought
possible obstruction was due to large stone, operation was certainly indica-
ted. April 3rd, she was removed to operating room and under general an-
esthesia following condition was found :
Extensive inflammatory condition, adhesions, to abdominal wall, stom-
ach, duodenum and transverse colon. Gall-bladder had been removed. Ad-
hesions were dense in gall-bladder fossa. After freeing them duct was
found to be completely obliterated by contracted inflammatory tissue except
about one inch entering the duodenum. After freeing duct it was found
so friable that even with delicate handling it promptly broke up under for-
ceps. After vainly trying to obtain sufficient duct to insert tube and make
an artificial tube it was found impracticable and I decided to anastamose
duct to duodenum. In this case unfortunately the hepatics joined low down
and I had to do the anastamosis at the junction of the two hepatics. This
was finally accomplished with difficulty. Five days after she had a profuse
hemorrhage from somewhere inside the wound which was stopped by pack-
ing and from that on she made an uninterrupted recovery. Jaundice
promptly cleared up and at the last report she was doing well.
In regard to injury of the liver this will occur only from carelessness and
usually where you have used metal retractors. The liver should be pulled
forward only by the hands of an assistant. Personally I have never seen a
primary cancer of the gall-bladder, only those from metastasis and here I
believe the patient should be best let alone. On two occasions I have seen
rupture of the gall-bladder several months after drainage with severe peri-
112 NORTH CAROLINA MEDICAL SOCIETY
tonitis. In both cases the patients were saved by free drainage of the abdo-
men and removal of the gall-bladder. In both cases the patients were ad-
vised to have gall-bladder removed at a later operation but they took mat-
ters into their own hands.
TREATMENT OF INFECTED BONE CAVATIES
Drs. D. W. & Ernest S. Bulluck and R. H. Davis
Wilmington^ N. C.
Infected bone cavaties are healed with great difficulty. The tendency is
toward chronicity. The process of repair seems limited and the result is
often disappointing. Regardless of the cause the essential condition is the
same — a chronic fistula of the bone with associated infection.
The pathology is that of osteomyelitis. The abcess may be simple or there
may be an involucrum and sequestrum. Such cavaties are covered with gran-
ulations and discharge by sinuses for long periods. Sargent ( 1 ) reports
such a case of sixteen years duration, and those existing for several years are
familiar to all.
The formation of new bone is not necessary for recovery, and it is diffi-
cult to understand why bone, a connective tissue, does not replace breeches
in its continuity with the same promptness that union follows fracture. It
is suggested by White (2) that incomplete restitution results from lessened
vascularity, due to the duration of the reparative process, osteosclerotic
changes progressively denser, thicker and less vascular, limiting prolifer-
ation. Such conditions as a rule are not found and there is little osteoscler-
osis. Sargent believes that the fibrous tissue has reached full maturity be-
fore the cavity is obliterated. As this tissue shows elsewhere great capacity
for reproduction, and as the lesion ultimately heals when the fibrous tissue
is even more mature, this view does not seem tenable. The proposition of
Martin (3) that this inactivity of the connective tissue, "may result from
environmental conditions, such as the desiccation and irritation of the granu-
lations by air, contact with dressings, solutions, surface bacteria and dirt,"
seem insufficient. The same conditions surround the breeches in all tissue,
yet they heal more promptly. A more plausible explanation of this tardy
healing seems to follow a consideration of the tissue in question. While
the bone marrow does have its origin in the embryonic mesoblast, in com-
mon with other fibrous tissues; it's confinement in the bone cavity, and it's
special function there, are not without effect on its primary characteristics.
Thus, it becomes more cellular than fibrous, more mitotic, but the newly
formed cells are discharged into the blood stream — having made no fibers.
Differences in moisture, consistency, color and in bacterial resistance serve
further to show that qualities common to areolar tissue are not necessarily
to be expected in bone marrow. The marrow only incompletely fills the
meduallary space. A cavity partly filled has reached the normal limit of its
compactness. Further healing is dependent upon sterilization from within
and closure from without. This closure takes place in a manner not gener-
ally recognized. The granulations covering the cavity do not increase in
thickness until the mouth of the cavity is reached, then protude from the
opening, become mushroomed above it, until by piling on at the edges it
becomes blended with the surrounding tissues. The healing it seems to us
SURGERY 113
depends upon relative sterility of the cavity, and the closure of the opening
is accomplished by adherence of overlying fibrous tissues, generally the peri-
mysium of adjacent muscles or their tendon sheaths. The sealing takes
place at the edges of the cavity where the covering is attached by plastic
adhesions to the vascular layer of the periosteum. At first the attachment
is incomplete and is only completed after such organisms as remain in the
cavity become latent. This fibrous door thickens by growing into the cavity
until the level of the endosteum is reached, where it blends with the vascu-
lar layer of that membrane. Thus, a fibrous plug is made, that fits into the
mouth of the cavity, and to wiiich later the bone marrow is lightly attached.
The fibrous plug may retain its character for years but is finally ossified.
Assuming that the mechanism of recovery is as here stated, we can readily
understand why these cavities opening at the inner side of the tibia are the
most difficult in which to effect a cure. We have to deal with a perforation
in the cortex that the bone itself cannot obliterate. To clean such a cavity
and pack it with gauze for drainage, hasmostasis, and to insure the skin re-
maining open until the cavity has closed by granulation from the bottom of
this newly made wound, seems to be a misdirected effort, for in so doing
the overlying tissues that would have served to bridge the mouth of the
cavity are pushed aside and so held until they become fixed in the new posi-
tion. The bone is incapable of producing the necessary granulation tissue
and of nourishing it while the gap is being repaired. The result is that re-
covery is difficult, delayed and sometimes impossible. The exposed and de-
nuded bone undergoes destructive changes that further complicates the pro-
cess of healing. If the old method is reversed and the overlying tissues so
closed as to favor their approximation to the borders of the cavity, the re-
sult will be much better. The bone is well covered and bathed in the cus-
tomary fluids. Drainage and irrigation through a single small tube is suffi-
cient.
We have to treat an infection of the bone and a hole in its cortex, to clean
the cavity and to close it. The infected surface should have its lining re-
moved in the most careful and S3'stematic manner, until every focus of os-
teitis and all necrotic tissue has been removed and the cavity converted into
an open gutter. Mechanical perfection is necessary to success; a tiny morsel
0^ tissue foreign body, or area of osteitis, may defeat the whole effort.
Scrapings after a cavity has been most carefully treated will reveal organ-
isms. Experience with bone grafts has shown that such organisms
may remain dormant for long periods and then regain their virulence, and
that a cavity may heal despite the presence of a very attenuated infection.
Antiseptics are not without value. The one per cer^t solution of Formalin
used by Ashurst (4) seems too weak, its action transitory and superficial.
Phenol is efficacious but it leaves the cavity lined with a layer of devitilized
tissue. Mosetig-Moorhof used the hot air blast, but question has arisen as
to the sterility of such air and whether at 100 degrees Centigrade this air
may not be injurious to the bone. To test this method Delbet curetted
cavities so treated and made cultures from the particles removed. The cul-
tures were alwaj's positive. • If he used Tincture of Iodine instead of hot air
the cultures were negative. For this and obvious reasons Iodine is the anti-
septic of choice and should be freely applied, after the cavity has been me-
114 NORTH CAROLINA MEDICAL SOCIETY
chanically cleaned. This work should be done under Esmarch's anaemia.
If impossible to do this hemorrhage may be controlled by the usual means.
In some instances — Brodies abscess and haemsetogenous osteomyelitis, — this
cleaning, with collapse of the soft parts is sufficient to effect a cure. (5).
The cavities infected with the pyogenic cocci show less tendency to heal.
Plugging the cavity with such pastes as have been advocated by Beck,
Neuber, Mosetig-Moorhof, or the Bipp (6) recently used by the English
has not been very successful, the good results accorded each particular prep-
aration being the reports of its originator. The cavities cannot be sterilized
and the paste becomes infected and is discharged. The experiments of Sil-
bermark (7) seem to rationalize these preparations, but he injected sterile
cavities in normal bone which is hardly a parallel condition. With each
however the soft parts are to be closed over the paste and thus a natural
approximation of the parts is accomplished, which is certainly better than
propping the wound open.
The disadvantage of a "foreign body" was obviated by Schede's method
of allowing the defect to fill with blood. This is practical in sterile cavi-
ties (Bancroft 8), but bone fistul^e are infected. Dorst has shown that the
susceptibility is increased 40 fold for the Staphyloccus if a hsematoma is
present. Skin sutured over a collection of blood will not heal satisfactorily,
even if there is no infection. A bone cavity filled with "something" is not
necessary for recovery. It need only be sterile and covered by fibrous tissue.
In this connection attention is called to a recent report by Albee (9) in
which he claims "that an efficient and trustworthy stimulus to osteogenesis
has been found in Triple Calcium Phosphate." A single injection of one
c.c. of a five per cent solution being sufficient to reduce the duration of treat-
ment twenty-six per cent in experimental fracture. Such an agent might
be applicable to bone cavities and by its action so stimulate the bone that
the bony tissue would share more activity in the reparative process.
The most rational method it seems to us, is to carefully clean the cavity
in the manner indicated, replace the soft parts in such a manner that they
will rest in gentle contact with the effected surface of the bone. The wound
is closed except for a small tube that leads to the cavity. The cavity is ir-
rigated with Daken's solution using the Carrell technique for bacterial con-
trol. After about two weeks the discharges are practically sterile and the
tube is slowly withdrawn over a period lasting about two weeks. If the
soft tissues could not be approximated to the bone at the first operation, a
secondary one is done after the wound has been sterilized. At this time the
types of tissue are approximated and held by suture. The gist of the treat-
ment rests in the cleaning of the cavity, the control of infection with Da-
kin's solution and the approximation of the adjacent fibrous tissue to the
mouth of the cavity.
BIBLIOGRAPHY
1. Sargent, P.: XXXII, Ann. Surg. Phila. 1919, p. 83.
2. White, J. Renfrew: Chr. Traumatic Osteomyelitis, Ann. Surg.
Phila. 1919.
3. Martin, Walton: The Treatment of Bone Cavities, Ann. Surg.
Phila. 1920, LXXI, 47.
SURGERY 115
4. Ashurst, A. P. C. : Indications for the Iodoform Wax Bone — Fill-
ing of Mosetig— Moorhof, Ann. Surg. Phila., 1917, LXV, 227.
5. Cheyne & Burghard: Manual of Surgical Treatment, Vol. Ill, n.
182.
6. Beck Jour. A. M. A., March 14, 1908.
7. Silbermark: Deut. Zeitschr fur Chir., 1904, LXXV, p. 290.
8. Bier: Med. Klin., I, 1905, p. 6.
9. Albee, Fred H., Studies in Bone Growth, Ann. Surg. Phila., 1920,
LXXI, 32.
CLOSURE OF BELLY WALL BASED ON THE HEALING
POWER OF TISSUE.
Henry F. Long, M. D., F. A. C. S., Statesville, N. C.
"In making an incision in the abdominal wall the anatomical layers com-
posing this wall should be considered, for if they are not the closing of the
cavity after the intra-abdominal operation has been completed may not be
satisfactory and may result in a weakened point in the wall which may
presently develop into a hernia, and this may be many times more serious
an affliction to the patient than the condition for which the operation was
undertaken."' This is a truth and an admonition coming from that great
surgical philosopher, A. J. Oschner, and this is the first key that unlocks the
difficulty to a successful belly closure. We must not stop here, however,
but after reaching the first point, which is a thorough and complete knowl-
edge of the anatomy of the belly-wall, we must take up each layer separately
and individually and study how it heals and above everythmg else how long
it takes each layer to form a safe and complete union, in other words the
healing time of each tissue involved. Before we study the various layers
concerned in an abdominal incision I want to lay down this dictum — that
we believe that only connective tissue heals to any degree of stability quick-
ly, and that the readiness and firmness with which any particular layer heals
depends entirely on the available connective tissue present, and I think that
I will be able to show you that this is correct from a biological, histological,
pathological and clinical standpoint. It is a general biologic law that the
lower the organism the greater are its regenerative powers and the stronger
its hold on life, for example, the ameba consisting of only one cell simply
splits and we have two, the ordinary earth worm cut in twain goes on living
as if nothing had happened, some of the lower organisms can even be turned
wrong side out and live right on, reptiles continue to grow till death while
man and the higher animals cease to grow at a certain age and so on ad
infinitum, the lower the organism in the scale of life the greater the regener-
ative and reproductive power and the greater its ability to live and carry
on these functions under unfavorable conditions. This same principle ap-
plies to tissues as well as to organisms, that is the more embryonic and sim-
ple a tissue the greater its power to regenerate and live, the less vulnerable
it is and the quicker it overcomes insults. I would say that the two ex-
tremes of tissue are represented by connective tissue as the lowest developed
and least specialized, and nervous and muscular tissue as the highest type.
Connective tissue is essentially a supportive tissue and has no specialized
116 NORTH CAROLINA MEDICAL SOCIETY
function. Muscular and nervous tissue are highly specialized and differen-
tiated and have special function to perform, these characteristics are devel-
oped at the expense of their regenerative power. Connective tissue will
grow in a test tube entirely separated from the rest of the organism. Car-
rell has carried a piece continuously over a period of twenty-eight months
and the cells were shown under the microscope to have actively multiplied
for two years. This shows conclusively that connective tissue has regener-
ative and reproductive powers far ahead of the others and that it will grow
and its cells multiply under conditions adverse to cell life. Please keep this
in mind, as the method of closure 1 shall describe is based on this fact and
clinical experience.
We will take as an example the incision in the lower midline. Here we
encounter from without inward, first the skin, then the fascia and going
through the linea alba we expose the sheaths of the recti muscles and lastly
the peritoneum. The layers then that we have to consider are the periton-
eum, aponeurosis, the sheath of each rectus, the fascia and the skin.
Now let us see what the peritoneum is, how it heals and the time of heal-
ing. The peritoneum is a thin shiny membrane covering the abdominal
viscera and lining the abdominal cavity. It is composed of connective tis-
sue on the "wrong side" and covered by a single layer of endothelium on
the smooth side. This structure is a "simon-pure" example of connective
tissue as the endothelial cells themselves are derived from the same embryo-
nic layer as connective tissue, (mesoderm.) Every one knows how readily
and firmly peritoneum stick together when irritated and placed in apposi-
tion. This is clearly shown in the form of adhesions following inflammatory
conditions in the belly. The process by which this takes place is as follows —
"When two laj'ers of serous membrane come to lie permanently and practi-
cally immovable upon each other there is a tendency to fusion between them,
the endothelium covering the apposed surfaces disappearing and its place
being taken by connective tissue." (Piersol's Anatomy.) This is caused
by the two surfaces along the line of contact throwing out liquor sanguinis
which rapidly separates into fibrin and serum, the fibrin forming a tempor-
ary cement and binding the two surfaces together. After this takes place
new connective tissues and new blood vessels are rapidly formed uniting the
two surfaces solidly. "The rapidity with which this preliminary aggluti-
nation occurs is well illustrated by the case reported by Oliver in which,
after five hours, a sutured intestinal wall had formed a water tight joint."
(Coplin's Pathology.)
Next let us consider the muscles. Muscular tissue is a highly specialized
tissue with special functions to perform which are developed at the expense
of its regenerative powers and does not take any part in the immediate heal-
ing of wounds. Muscles do not heal to any degree of stability, but can be
trained to lie in certain positions. The pathologists tell us that repair of
an incised wound of muscular tissue takes place entirely by granulation and
scar tissue formed from the fibroblasts adjoining the incision, and that the
muscular tissue itself makes only a feeble effort at regeneration.
Fascia and aponeurosis tend to heal slowly although they are of connec-
tive tissue origin. The reason for this is that these tissues are compact and
SURGERY 117
rather poorly supplied with blood causing the exudation of fibrin and the
formation of new tissue to be rather prolonged. These layers however,
make a very strong union when properly coapted.
Fat heals lightly if at all. It is poorly supplied with blood, its resistance
is exceedingly limited, hence it breaks down easily and regenerates poorly.
Lastly let us consider the skin. Histologically the skin is composed of
stratified squamous epithelium which is supported underneath by a very
generous supply of connective tissue. In this tissue lie the blood vessels,
nerves and lymphatics of the skin. The rapidity with which skin heals is
a well known fact. This truth gave rise to the old adage "that wounds heal
too quickly." Every surgeon has seen wounds that looked perfectly healthy
from the outside, the skin having healed beautifully, which on further ex-
amination showed that the bottom layers had not healed at all, and that
deep down in the tissues below the skin pus was present. In the healing of
a skin incision the epithelium takes a minor part, although it covers the re-
sulting scar the real tissue that is holding together and giving strength to
the wound is the dense white connective tissue below, the chief part played
by the epithelial covering being to prevent a weepy surface. The conclu-
sion to be drawn from this is that the portion of the skin that really heals
and gives strength to the incision is the connective tissue base. We take ad-
vantage of this as 3^ou will see later on.
Before describing the technique let us summarize just a little so as to see
the significance of what we have been over.
First — Only connective tissue heals rapidly and gives immediate solidari-
ty to the union.
Second — Peritoneum, being connective tissue, is a rapid and solid healer.
Third — Muscles heal very slowly and slightly, but may be trained to lie
in certain positions.
Fourth — Aponeurosis forms -a stout union, but is a little slow.
Fifth — Fat is a very poor healer.
Sixth — Skin is a rapid and safe healer, only the connective tissue base
heals immediately and firmly.
The technique of our closure is as follows and is based on the above find-
ings. In describing the technique we will presume that the incision has
been made and the various layers exposed. Now we begin by loosening up
the peritoneum on the opposite side of the incision so as to have a flap to
pull up between the recti muscles. We use an interrupted suture of catgut
going through first the rectus muscle, say on the left side, then through the
peritoneum of the. same side well back from the margin, then taking a liberal
bite in the peritoneum on the opposite side well back from the margin (mat-
tress fashion) then back through the peritoneum on the same side and out
through the rectus muscle. This is continued all the way up until the in-
cision is closed and the result is that you have two layers of peritoneum
(rapid healer) brought up between the recti muscles (slow healer). The
next step is to bring together the sheaths of the recti muscles and the apon-
eurosis, this is done in such fashion with an interrupted silk worm gut
suture as to make a surface union instead of an edge to edge (lap over). We
make no effort to close the fat, but our next attention is directed to the skin.
118 NORTH CAROLINA MEDICAL SOCIETY
With a straight Hagedorn needle armed with horse hair we close the skin
with a mattress suture so as to give a broad surface union avoiding the edge
to edge coaptation. This same principle applies to the McBurney incision,
to the right and left rectus incision, to the Camera incision, also the incision
in the upper right quadrant usually made for operations on the gall-bladder.
I have carried this principle on and in all operations for ventral hernia I
use the peritoneum and skin, rapid healers, to make the contracted and re-
tracted muscles come together and stay together. I have carried it on to
inguinal hernia in the following manner — when I have dissected out the sac,
which is peritoneum, I at once drop it into hot saline solution and when I
am ready to close up I sandwich it between Poupart's ligament and the
conjoined tendon of the internal oblique and transversalis muscles thus glu-
ing them together. I have also used this same principle in the correction of
ceacum mobile by pulling up the ligament of the ceacum and anchoring it
in the incision.
The writer has been closing in this manner for about eight years and if
I had all of them to do over again I would not change my method; and
only the finding of something better will cause me to change in the future.
DISCUSSION OF DR. LONG's PAPER
Dr. E. M. Summerell, China Grove : We have all heard Dr. Long's
paper, and I trust that we have all most thoroughly enjoyed it, the more es-
pecially since it presents to our view an extensive vista of relief for suffer-
ing humanity. It should be a source of great satisfaction to us, if not of an
equal amount of pride, that the author is a North Carolinian and a mem-
ber of our Society.
One criticism I have to offer, and that is that it is too brief, but possibly
the doctor's excuse lies in the same line as Sam Weller's, that the chief
secret of successful writing lies in leaving the reader to wish that there were
more of it.
Hernia is one of the chief opprobia of the surgical profession. It is
either congential or acquired. As acquired it is due to mechanical violence,
which, of course, includes surgical procedure. Every opening of the abdom-
inal wall demands at the hands of the surgeon his most particular care and
attention to prevent the occurrence or recurrence of a subsequent profusion
of the visceral contents. It is proposed in this paper to show us a plan, a
simple one, by which this object can best be attained. The method Dr.
Long has most clearly indicated. Now, let us consider the why of this. On
what scientific basis are the statements of Dr. Long grounded? To my
mind, the reason for the truth of his conclusions depends upon the recogni-
tion of certain simple anatomical, histological and pathological facts. Ana-
tomically, we have three membranes in the human body: dermal, serous,
and mucous. Histologically, these membranes all h!ave certain qualities in
common, to only one of which I shall call your attention today. Pathologi-
cally, we shall have drawn our conclusions.
The one simple condition common to all of these membranes is the great
quantity of lymphatics found in all of them. More than that, these mem-
branes all possess more lymphatics than any other tissues in the body. The
importance of the contents of these lymphatics — the lymph — in the process
SURGERY 119
of repair can not be over-estimated. It is histologically known that these
vessels, whether saccular or vascular, are lined with a most delicate endothe-
lium, the component cells of which, when irritated, become clearly individu-
alized. And not only so, but stomata appear between adjoining cells, facil-
itating the escape of the vascular contents. There has been demonstrated
in the fluid both fibrinogen and fibrinoplastin. In the presence of irritation
the capacity of the cellular contents to undergo great proliferation is vastly
enhanced. It is known that the progeny of the proliferation of these lymph-
atic cells is the chief, if not the only, source of the connective tissue so nec-
essary for repair. I suppose that you will all agree that the firmness and
solidity of the union of any incision depends upon the firmness and amount
of the connective tissue therein developed.
In the plan that Dr. Long has shown us so clearly and lucidly, he makes
an effort to reinforce the incision by securing the production of as large an
amount of connective tissue as possible in the scar. To do this, he secures
material with as great capacity for producing tissue as possible. This he
obtains in situ. As he tells us, he uses the redundancy of the peritoneum,
which happens to be the richest of the three membranes I have mentioned
in the quantity of lymphatics. As a first step, he laps one margin of the
peritoneal incision considerably over the other, and unites the two layers
firmly with through and through sutures. Any free margin he carries up
further into the incision and unites to convenient tissue, thereby reinforcing
and strengthening the whole depth of the wound. By this simple technique
of Dr. Long's the strength of the scar is much increased and the incidence
of subsequent hernial protrusion correspondingly diminished.
But there is another membrane he calls upon to add its quota to the se-
curity against hernial protrusion — the skin. This is done by mattressing
the deepest layers (those fullest of lymphatics), the consequent irritation of
which furnishes further reinforcement and strength to the scar.
In conclusion, I trust that you will all agree with me that the facts nar-
rated in Dr. Long's paper constitute a distinct and marked^I might say an
epochal — advance in the surgery of the belly wall.
HYPERTHROPIC STENOSIS OF THE PYLORUS.
Dr. E. T. Dickinson, Wilson
After talking with a number of surgeons and pediatritians on the subject
of congenital hypertrophy of the pylorus, and learning of the decidedly un-
equal experiences of these men with this trouble, I decided that a discussion
here might prove interesting to us and profitable to many little ones yet un-
born.
As the subject is barely mentioned in text-books except of the most recent
issue, it is likely that most general practitioners entirely overlook this mala-
dy of the infant, or too long mistake it for a little indigestion. For a decade
or more the writer never suspected a case, then after gaining some knowl-
edge of its existence as a pathological and surgical condition, he found these
cases not so frequently, to-be-sure, as appendicitis and cesarean section, but
of sufficient frequency to prove decidedly interesting.
I am merely calling attention to the existence of this trouble, and to the
salient diagnostic points leading to its differentiation from the common
120 NORTH CAROLINA MEDICAL SOCIETY
forms of indigestion and the transient abnormal functions of the stomach
and pylorus. My experience does not lead me to boast of any particular
method of treatment, having been ultimately unsuccessful with the few
cases treated. This fact should not discourage hope for discussion, as I un-
derstand the usual salvage is about fifty per cent, of the operative cases. My
cases have unfortunately not been properly operative because of having been
brought too near the grave before operation was allowed. It is to the best
interest of all concerned that the profession and the public be informed on
the point of necessity of early recognition and proper treatment, before the
infant has lost the vitality necessary for the effort.
I feel sure these cases occur in the practice of most practitioners who treat
mothers and their infants more often than is generally recognized, because
several loomed up in my practice very soon after I had learned of its exist-
ence, as did also in the practice of my partner, and because I seldom see one
or hear of one from other clientiels.
The sj'mptoms of this malady are so distinct in cases so developed as to
need operative treatment that there can hardly be a doubt in the mind of
the practitioner, even after a perfunctory examination.
The infant does not grow or loses weight in proportion to the thicken-
ing of the sphincter muscle of the pylorus and the consequent closure of the
pyloric orifice. His appetite is good and he takes food in a normal way,
and retains it a variable length of time.
Sooner or later he vomits in a rather characteristic way, the contents be-
ing forced in a stream for several inches from the mouth, called eruptive or
projectile vomiting.
At frequent intervals before vomiting occurs the outline of the stomach
may be noted on the abdominal wall and the peristaltic waves can be plainly
seen.
After the vomiting careful palpation of the abdomen in the region of the
pylorus will often reveal a distinct marble-like tumor which is fairly mov-
able.
A few drachms of bismuth subnitrate given in milk followed by x-ray
examination will give a working knowledge of the degree of stenosis.
Even in cases of complete stenosis the stools may be of sufficient volume
and frequency to satisfy the mother or the nurse, but proper examination
will detect a marked deficiency, and the color and consistency will be far
from normal, being dark, tarry and tough, or consisting almost entirely of
bile, or of bile and mucus.
Treatment of these little cases should be well directed by a physician
who knows much more of the pathology than the mother or nurse could
possibly be impressed with. Left to the imagination of the loving mother
and sympathizing friends these infants drift too far into starvation and the
vicious circle of malnutrition.
Certainly some cases of partial stenosis recover. These cases show a
stream of bismuth passing the pylorus very soon or immediately after the
meal has been given. They should have bismuth and antispasmodics as thera-
peutic measures and a carefully regulated diet of milk, either mother's milk
or modified milk as may be found to suit the individual case. Systematic gas-
tric lavage is also instituted early and persisted in until recovery has taken
place or more radical measures have become evident.
SURGERY 121
Operation should not be delayed until it is dangerous on account of ex-
cessive starvation. Two operations are advocated. Posterior gastroenter-
ostom}' which was the first operative procedure in these cases is still done and
advocated by some. The Rammstedt or the Webber-Rammstedt operation
seems to be the favorite of most operators at the present time.
In this procedure the abdomen is opened through the right rectus above
the umbilicus. The tumor is delivered and while held firmly between the
thumb and the forefinger of the left hand, an incision is made into the tu-
mor in the line of the axis of the gut, extending the full length of the swell-
ing. This incision is carefully deepened until the m.ucous membrane begins
to bulge into it. With scissors the muscle is gently separated from the
mucous membrane and the incision stretched open so that the mucous mem-
brane is exposed for a width of an inch or more. If the stomach be distended
slightly at this time with air it can readily be seen to pass freely through the
pyloric opening. Or if a small stomach tube has been left in the stomach
after the lavage it can be readily passed through.
DISCUSSION OF DR. DICKINSON^S PAPER
Dr. 1. W. Faison^ Charlotte: I am no surgeon, by any means, but
I do have something to do with pyloric stenosis. Diagnosis
can be made pretty easily with the x-ray and bismuth, but
if you use your head, you do not need either. When these little fellows
swell up and you see repeated perstaltic waves, j-ou can easily recognize
the condition. An operation is needed, though a few of them may get well
without it, but too few get well to think of taking a chance without it. They
recover rapidly. The principle is the same, that the muscle is cut through
on the anterior portion of the stomach to the mucous membrane. One man
would dissect the serous coat of the stomach and suture it over the cut mem-
brane. Others stitch the omentum over the cut surface. I have one baby
in the hospital now, four months old, who weighed eight or nine pounds
when he was born and weighed seven pounds when he was operated on. He
vomited almost everything. The trouble with these babies is that they are
not turned over to somebody soon enough. That is too often the case, and
it is too bad that the regular medical men will hold these little fellows un-
til they begin to see the budding wings and then want to shift the respon-
sibility. The operation was beautifully done, successfully done, scientifical-
ly done. The baby's temperature went down at once, though it has been
to \O\y2 since. We began feeding him within half an hour. If you had
seen that baby last Monday and saw him today, you would doubt that it
was the same baby. Every case, as Dr. Deaver says about appendicitis, be-
longs to the surgeon and not to the doctors. When these little fellows get
<5ick they belong to the pediatrician and not to the doctors.
DISCUSSION of dr. dickinson's paper
Dr. J. Buren Sidbury, Wilmington: I wish to bring out a few
points in the symptoms of these little fellows. First, and most important,
it seems to me, is the age of the patient. If a child is having projectile
vomiting for the first time, at ten months of age he has not pyloric stenosis.
Usually the vomiting begins from birth and is projectile in character. The
baby may have nothing in its stools except meconium, he is usually consti-
pated.
122 NORTH CAROLINA MEDICAL SOCIETY
In describing the wave that is found in this condition, it starts on the
right side, travelling somewhat like a rubber ball across the median line to
the left, rhythmical in character and wave-like. Some times it goes in the
opposite direction, at which time the child vomifs. In regard to the tumor,
that is one of the least valuable signs. At autopsy I have seen recently two
cases, which died at nine and twelve months of age of other conditions. The
tumor, the thickening of the pylorus, was still present. There is no tendency
of these fibres to reunite and cause the symptoms if all the muscle fibres are
divided.
In regard to the technique of the operation, there is one addition, so far
as I know. Two of Dr. Bowne's cases at Babies Hospital suturing of per-
itoneum over the cut surface of pylorus which were operated on in the last
four months died of hemorrhage. They were autopsied, showing that the
only cause of death was hemorrhage. To relieve this, he has advocated
suturing over the cut surface a layer of the peritoneum which will avoid
hemorrhage. A very small hemorrhage may cause the loss of life in these lit-
tle fellows. He advocates that this procedure be adopted by the surgeon as
the means of preventing this secondary hemorrhage.
In the routine of determining whether or not a child has pyloric stenosis,
two or three things would be done before the child is turned over to the
surgeon. First, the stomach should be washed out ; second, he should be
given water to see the gastric wave; third, is the retention. Three hours
after feeding the stomach should be washed out to see how much of the food
is retained. In a normal baby at that age nothing should be left in the stom-
ach at all after three hours. This procedure will give you some definite
idea of the functioning capacity of the pylorus. The stomach content is
not bile-stained. If there is any regurgitation of bile the possibility of
duodeneal obstruction of some kind should be considered, rather than the
possibility of plyoric stenosis. I agree with Dr. Faison in regard to the x-ray.
The less these little fellows are manipulated the better. The simple watch-
ing for the gastric wave, the determination of the amount of food passing
through the pylorus or the amount of retentions, will give you more infor-
mation than all the x-ray men.
There is one point which I do not think has been brought out, and that
is that when a child has lost one-third of his body weight that is the danger
signal. Patients who come to operation before they have lost one-third of
the original body weight are likely to have a favorable outcome of the oper-
ation. While patients who have lost more than one-third will not do so well.
See that the child does not lose more than one-third of his body weight. Be-
yond that is the danger period. These cases, like any other cases of maras-
mus and malnutrition, are feeding cases. The child is still a problem after
the operation, and may be a difficult feeding case all its life. The feeding
is a problem for the pediatrician. As Dr. Faison has said, feed them early
and increase gradually until the child is able to take care of the food that
you give. One most important point is this, these children need breast milk.
That will do more for them than any other thing except the surgeon. With-
out a skilled surgeon and without breast milk the child's chances for life
are very, very uncertain.
SURGERY 123
Dr. Dickinson, closing the discussion: I want to say that I am very
grateful for the liberal discussion of this paper, because this subject is in its
infancy and I do not feel that the treatment will be successful until the pro-
cedure is far in advance of the present. No treatment is successful when
there is a fifty per cent mortality, and there is no method at present of deal-
ing with this congenital stenosis of the pylorus that gives better hope than
fifty per cent.
"END RESULTS OF ONE HUNDRED CASES OF CANCER
OF UTERUS"
Dr. J. A. Williams, M. D., B. S., F. A. C. S., Greensboro
I am not going to take up your time giving you statistics in regard to
Cancer of the Uterus. We all know that thousands are dying every year
from cancer, having its incipiency either in the cervix or body of the uter-
us. Of the one hundred cases in this report, seventy per cent were diagnos-
ed early and a complete hysterectomy followed. Ten of these had a re-
currence within three years and finally died. Two others had cancer of the
liver two or three years later. Thirty were living two years later and in
good health. Twenty were in good health five years after operation. Eight
were living and in good health eight 3'ears after operation.
The above cases were in the earliest stages, the thirty remaining were ad-
vanced cases bordening on what we would consider the border line operable
and unoperable cases.
I used Percy cautery on four of these for fifty minutes and in twelve or
fourteen days did a complete hysterectomy on three. Of these all but two
had recurrence within six months and died. On died of hemorrhage four
days after cauterization, due to slough, before we had a chance to reopen
and do a hysterectomy. One living six months after, with mass in pelvis
but no indication of recurrence in vaginal mucus membrane.
Six cases proved to be epithelioma of cervix and by wide dissection of
vaginal mucos and abdominal hj'sterectomy, all of these are living from
two to four years.
The twenty left were unoperable, three were simply cauterized to stop
hemorrhage. The rest were advised to use raduim but not being able, eight
went home to be treated as best they could by family physicians. Nine
others went to various places and used six to twelve treatments of radium
at different periods. Two died in four months after return, two in six
months. Two others in eight months and one other in one year. The other
two, so far as I can see, radium has had no effect on, as there are large
masses involving rectum and bladder, though they are still living. The
radium stayed the disease perhaps but otherwise, I can see no results.
(conclusions)
I — That radium or Percy cautery may help stay the growth for a while
but no permanent results.
II — That until the physicians examine their patients at intervals after
child birth and keep tab on the irritation from laceration and from abortion
and get the patient to be operated on early, there is no hope.
124 NORTH CAROLINA MEDICAL SOCIETY
in — The public at large and especially the women must be educated to
this fact and demand the exam'ination earh-.
IV — That the great responsibility of this educational work rests on the
family physician. Then and not until then will we see a decrease death
rate from cancer of the uterus.
V — That my belief is, that if radium proves a curative of cancer, it must
be used in the earliest stages of the disease and then not get any better re-
sults than the old teaching of dissecting operations, as it has been proven
that radium is only effective in cancer of the cervix. I would prefer opera-
tive procedure until they prove more to my satisfaction than the present,
the efficiency of radium treatment.
SUBPHRENIC ABSCESS.
George Wm. Pressley, M. D., F. A. C. S., Charlotte, N. C.
A subphrenic abscess is a collection of pus in contact with some portion
of the under surface of the diaphragm. It is then not a subhepatic, or a
perirenal or a liver abscess.
Fortunately it is a rare condition but at the same time it is a very serious
one when it does occur. The man with very large surgical practice will see
about two cases in a year ; with very good practice about one a year ; the
average surgeon one in two years. This rarity of the condition tends to
catch us unprepared and we lose valuable time in making the diagnosis, in
fact we make our diagnosis in not a few cases afterwards.
The disease only dates back to 1845 w^hen Barlow had a few words to
say about it. No one paid any attention to him for thirty odd years when
Volkman operated on a case and it was not till 1880 that a clean-cut diagno-
sis was made before operation when Von Leyden wrote his epoch-making
paper. Since then we have known much about it, in fact much more than
we have practiced perhaps.
We have two main classes of cases ; post-operative and pre-operative.
These can be divided into acute and insidious. The acute are usually rup?
ture cases, the insidious are post-operative.
Barnard in the British Medical Journal, No. 1, 1908, gives us a very de-
tailed description of the anatomy of the under surface of the diaphragm
which is very helpful in explaining the pathology of this abscess. The cru-
cial arrangement of the hepatic ligaments divides the inferior surface of the
diaphragm into four compartments right and left anterior and right and
left posterior. These four spaces are lined with peritoneum. The two
anterior spaces are large while the posterior are small. Then we have two
spaces, a right and left uncovered by peritoneum. On the right this extra-
peritoneal space is in the folds of the coronary ligament, while on the left
it encloses the upper pole of the kidney. This arrangement serves admir-
ably when all is well but in the presence of infection, like the pockets in the
knee-joint, only more so, it adds immensely to the gravity of the situation.
Further we remember that there is a depression in the superior surface of
the liver called the cardiac depression but which serves as the touch hole or
SURGERY • 125
Starting point for this infection. As a general rule the abscess does not
break through the falciform ligament and so remain right or left as the
case may be whether intra or extra peritoneal. Most are right sided, in
fact, we rarely see the left-sided kind.
Causes are as follows:
1. Rupture of hollow viscus as stomach, duodenum, appendix, gall-blad-
der or esophagus.
2. Suppuration in adjacent organs as infection of spleen, liver, kidney,
lungs or pleura.
3. Infected ribs, vertebra or abscess of the thoracic wall along the line of
the diaphragm.
4. Trauma, hematoma, foreign bodies as bullets, shreds of clothing or
empyema drainage tube.
5. Metastasis of local infection as carbuncle, felon or tonsil.
6. Localization of general infection as in lagrippe.
The right-sided abscess is usually of appendiceal, gastric, duodeneal or
hepatic origin.
The left-sided splenic, renal, gastric or esophageal.
The germ most usually found is the colon bacillus, next the streptoccus,
in some cases the pus is sterile at time of operation especially if long delayed
the orginal focus having been removed.
Quite a few cases give a history of amebic dysentery but no ameboid or-
ganism can be found.
In 1204 cases from the literature and private communications we have
the following:
Due to appendix 322
stomach 280
gall-bladder, liver 181
duodenum 82
spleen 45
t. b. abdomen ' 29
pancreas 28
trauma 26
female genitalia 17
kidney 7
pleura 6
general peritonitis 4
costal 4
focal infection 3
undetermined 75
96 loosely stated as mostly appendix, next liver and gall-bladder, few
stomach, duodenum, kidney, liver abscess, trauma and undetermined. In
129 recent cases, 100 recovered, 22.5% mortality
In 890 cases previous to 1910, 30% of the operated cases died.
126 ' NORTH CAROLINA MEDICAL SOCIETY
The three operative routes gave the following:
Abdominal 214 cases,, 36% mortality.
Transpleuro-diaphragmatic 201 cases, 33% mortality.
Lumbar 47 cases, 23% mortality.
In 990 cases, 739 were intraperitoneal, 151 extraperitoneal.
CLINICAL HISTORY
Onset sudden or may be insidious.
If sudden the patient is seriously ill with upper abdominal pain, nausea,
vomiting, pain hard to control andl vague as to exact location ; may be epigas-
tric, then diffuse abdominal, in the back, then chest or shoulder, or subclav-
icular, this last being fairly characteristic. Temperature may be subnormal
for first few hours then up to 102. Chilly feeling in back and in some cases
early cough and expectoration. Tenderness delayed several hours to sev-
eral days, under costal margin on right side, epigastric or in chest or back
or loins. Maybe absent in some cases throughout illness. Hiccough may
be very troublesome. If insidious, the patient does not improve after oper-
ation for some suppurative abdominal condition. Anorexia, coated tongue
in spite of regular bowels movement. Slight temperature, 99 to 101, short-
ness of breath on least exertion, cough, dyspnea, sallow complexion, pinched
facies, visible alae nasi movements with respiration, chills and sweats,
wound doing well, every thing all right except the patient
TERMINATIONS ^
1. Pus may become encapsulated. Very rare.
2. May rupture into bronchus. Pus coughed up.
3. Rupture into alimentary tract.
4. Rupture into pericardium.
5. Point at unbilicus or in the loin.
Mortality depends on time of operation, if too early you miss the pus, if
too late you miss the patient.
Average operative mortality 35 to 50%.
After acute cases patient may improve week or more, temperature and
pulse to normal, some appetite, able to be up some with quart pus in sub-
phrenic space.
DIAGNOSIS
The diagnosis is most frequently made by exclusion.
If you have a patient with some serious suppurative upper abdominal
condition that you cannot possibly locate at all an3avhere, the chances are
that the patient has a subphenric abscess.
The temperature is not especially significant, may be high or normal.
Morning normal is the rule in many cases. Late in the disease the tem-
perature is of course pyemic in type.
Pulse usually out of proportion to temperature elevation. In many cases
however, the pulse will be normal, at least for the first half of the day.
SURGERY 127
Pain is severe and early in the rupture cases, may be slight and late in the
post-operative cases. In both instances it is variable as to location, may be
diffuse abdominal in the morning, thoracic in the afternoon, then in the
back or loins. The supracavicular pain is said to be fairly characteristic.
Tenderness is more or less conspicious by its absence.
Leucocyte count always high, 18 to 40 thousand. One of the most help-
ful signs.
X-ray shows a high riaphragm more or less fixed, low liver line and fre-
quently fluid shadow in the pleura.
Physical signs are triangular line of upper liver — border dullness, reach-
ing its highest point in the mid — or anterior axillary line; epigastric dull-
ness in sitting posture which disappears on lying down ; lateral excursion of
the costal margin on affected side. In long standing cases there may be
bulging of chest or abdominal wall or in the back.
Aspirating needle is the proof of the pudding if positive, if negative of no
value. Needle should be of large caliber, at least three inches long. It
should be put in deep in center of dullness and bulging if any and suction
kept on all the time, watch for air or serum but if these appear in the bar-
rel push on.
COMPLICATIONS
Liver abscess, the most common and most frequent cause of death, pleuri-
sy with serous or purulent exudate occurs in about one-third the cases. Per-
icarditis which may be serous or suppurative in character. Pulmonary ab-
scess and septic pneumonia may be seen in many cases.
TREATMENT
The treatment is obvious, early free drainage. Do not pay much atten-
tion to the original focus.
Burke in Anals of Surgery, Oct. 1918, advises anterior incisions in
all cases with counter drain if needed. Others recommend resection of 9th
or 10th ribs. Possibly better both ribs and push up the diaphragm or the
pleura can be opened in two stages or immediately by suturing the upper
edge of the cut plura to the diaphragm and packing behind the proposed
opening in the diaphragm. Use large tubular drains follow up extension if
to pleura, lung or loin. If to liver the case is hopeless.
NOTE — I am greatly indebted to the surgeons who answered the ques-
tionaire sent out and thank them very heartily for their replies.
ASCARIASIS AS A SURGICAL COMPLICATION
Henry Norris, M. D., Rutherfordton, N. C.
You are all. no doubt, so familiar with the life history of the Ascarsis
Lumbricoides that I shall not attempt to describe it as I merely wish in this
brief paper to call your attention to the apparently very serious symptoms
which may be caused by these worms after surgical operations.
I am sure that many of the surgeons here present will agree with me that
it is an exceedingly rare thing to ever palpate a living worm in the intestine
during the course of a laparotomy. In only one abdomen have I ever en-
128 NORTH CAROLINA MEDICAL SOCIETY
countered a worm which was moving. In this case, a colored woman, whom
I operated upon for some minor pelvic condition, through a median abdom-
inal incision, I reached over to draw up the cecum and have a look at the
appendix, and to my surprise felt something wiggling under my fingers. I
brought up a loop of the ileum and could plainly see and feel within it the
outline of a round worm ; placing a lap pad about the gut, I made a small
.incision into it and drew out a worm fourteen inches long, which was very
much alive. The nick in the bowel was closed and the appendix was then
removed.
The reason that we do not feel living worms while doing abdominal op-
erations is because they are narcotized by the ether. Probably many of
them recover from ether as does the patient, while undoubtedly numbers ot
them are killed by the anaesthetic. It is to the latter group that I wish to
call your attention.
In September, 1908, E. S., Male, age 12 years, was admitted to the Ruth-
erford Hospital with a diagnosis of acute appendicitis, which was concurred
in, immediate operation was advised, and performed. The appendix was
found to be acutely inflamed, gangrenous near the tip and contained two
concretions. The abdomen was closed in our routine manner and for forty-
eight hours the post-operative condition of the patient was all that could be
desired. His temperature then shot up to 103, pulse 140, respirations 28.
His abdomen was slightly distended, but was not rigid, peristalsis was of
very poor quality and the boy looked desperately ill. His tongue was very
dry and his breath was peculiarly offensive. His wound was examined and
found to be clean. A white cell count showed a slight leukocytosis. He com-
plained of feeling very nauseated, but for several hours did not vomit, he
then brought up a large dead round worm, twelve inches long. By the
next morning his symptoms had returned to normal and his convalescence
was entirely uneventful, except for the passage of two small worms follow-
ing the administration of Santonin and Calomel. Since this case, we have
had eighteen or twenty similar ones and are able to recognize the symptoms
described above as due to the presence of a dead worm or worms, either in
the stomach or small intestine. In the former location the symptoms are
always more severe and patient appears more ill. The breath has an al-
most death-like odor. Pain has not been complained of by those patients
who vomited the worms, but in cases in which the lubricoides were expelled
from the bowel, cramp-like pains were experienced in the neighborhood of
the umbilicus.
The symptoms are rather suggestive of peritonitis, except for the fact
that there is no pain, peristalsis does not cease, abdomen does not become
rigid and there is no vomiting until the ejection of the worm. A number
of years ago I saw a post-mortem made upon a man aged about forty, who
died with a clinical diagnosis of acute catarrhal jaundice following pneumo-
nia. A large round worm had entered the common bowel duct and com-
pletely occluded it.
In those cases which we have in the Hospital a sufficient length of tirne
before operation, routine examination of the stools prevents what is a dis-
tinctly alarming, and I believe, not uncommon surgical complication.
SURGERY 129
THE SURGEON AND ROENTGENOLOGY.
Dr. R. H. Lafferty, Charlotte, N. C.
To saj- the roentgengram and its accurate interpretation is practically in-
dispensable to the surgeon is today a trite remark. It is universally recog-
nized. The great war did much toward giving it its rightful place and the
great dependence that both surgeons and clinicians place upon it is shown
by the number of x-ray illustrations we find in our best journals and see at
various medical ;iieetings. While in so brief a time it is impossible to enu-
merate the many uses, it may not be amiss to mention a few and illustrate
some of them.
The localization of foreign bodies reached its climax during the war, but
in cival practice it is of great assistance. All can recall how we used to probe
and probe for a bullet and then stop and wonder where it was. In deter-
mining fractures and dislocations and in ascertaining the position of the
bones we have such a well recognized and ready help in time of trouble that
it is hardly necessary to mention it. Then in determining the nature of a
bone lesion it may often save us much useless worry and occasionally the
patient a useless operation.
Over and over again the x-ray has been of service to the surgeon and in-
ternist in locating pus pockets, which had not been reached by a needle and
in determining the presence of fluid in the lung ; also in a study of the con-
dition of the sinuses and antra.
When we turn our attention to abdominal lesions no one diagnositic
procedure, unless it be Dr. Deaver's "diagnostic scapel" can equal the
roentgen ray in importance. While the gall stone is not located readily, it
is at times demonstrated and more often indicated by surrounding condi-
tions.
The kidney calculus, ureteral or bladder stones can easily be located and
we have not infrequently seen patients who might have saved an appendix
and lost a kidney stone had the roentgen ray been emploj^ed before the op-
eration. The location of many pathological conditions of the alimentary
tract and surrounding organs, the presence of adhesions and of many chron-
ic appendices may be shown. To stop here to discuss what constitutes
roentgenologically a pathological appendix would consume too much time —
sufHce to say that every appendix that is visualized is not pathological.
The barium meal (the priority of the use of which, has been clearly
shown (1) was not German, but A-merican) marked an epoch in the field
of x-ray diagnosis. The advent of the pneumoperitineum marks another.
By the injection of gas into the peritoneal cavit}^ one may show clearly all the
softer tissues, as the heart is seen embedded in normal lung tissue one may
locate tumor masses and adhesions, differentiate between an abscess above or
below the diaphragm and ascertain other conditions that we have longed to
know. It has not, as vet, come into very general use and no bad results
have been reported. Stew-art of N. Y. (2) and OrndofE (3) of Chicago
have no bad effects to report in over 200 cases. No one has yet seen enough
cases to have become expert in interpretation, but it offers to us a new and
very inviting field of study.
130 NORTH CAROLINA MEDICAL SOCIETY
Finally in the field of therapuesis the x-ray comes as an important ally to
the surgeon. Following the removal of every malignant or suspicious
growth the x-ray should be applied. It will undoubtedly lessen recurrences
and make your work more successful.
In conclusion I might say that it is the desire of the roentgenologist to
serve the surgeon and clinician in diagnosing cases and in becoming as
thorough as possible in examining a case. He has no desire to usurp their
position in clinical study and in treating or advising the patient. I might
venture to prophesy that in ten years from now there will, be thousands of
unused x-ray machines sitting around in doctors' and dentists' offices just
as there were, and probably still are, static machines by the hundreds. The
busy doctor will decide that he has no time for the work and interpretation
of the plates.
REFERENCES
1. Am Journal of Roent., Vol. 2, No. 5, page 692.
2. Am. Journal of Roent., Vol. 6, No. 11, page 533.
3. The Journal of Roent., Vol. 2, No. 3.
A TROUBLESOME COMPLICATION OF GONORRHOEA
ITS TREATMENT.
Hamilton W. McKay, M. D., of the Crowell Urological Clinic,
Charlotte, N. C, Former Major M. C, U. S. A.
Like the poor, gonorrhoea with its manifold complications and far
reaching results will always present a problem worthy of careful considera-
tion and study.
Even though we are living in an age of turmoil and unrest, of unions
and strikes, it would be difficult to convince the genito-urinary surgeons
that the gonococcus is a member of any union or will submit to an eight
hour law. The never ceasing labors of this much dispised organism is re-
sponsible for much of the income of the specialist whose labors are confined
to the genito-urinary tract whether he be known as urologist, genito-urinary
surgeon or venereal specialist.
By the assembling of four million of our young men we, who are inter-
ested in the study of venereal diseases, had ample opportunity for study of
one the foremost medical problems of the present day. In my opinion if the
moblization of our army has taught any great lesson about the control and
treatment of venereal diseases it is in brief, that we must put aside false
modesty, secrecy, and prudery. Why should physicians whisper about
Florida's 15.63% venereal rate or Vermont's 1.2% venereal rate? They
should consider these conditions just as any contagious or infectious disease
should be studied and proper steps taken to remedy the same. Venereals
must be both spoken of and treated as infected members of society, each
case being a law unto itself.
Since 1917 splendid work has been done to bring these diseases before
the profession in a way w^hich is both beneficial to patient and doctor, and I
am thoroughly convinced that we cannot successfully treat the above unless
SURGERY 131
we are interested enough to give sufficient time, thought, and study to the
pathology in each individual case. With out present knowledge of patholo-
gy which the gonococcus produces we should not have fixed in our minds
any routine or standard method of treatment for the so-called specific ureth-
ritis but we should think in terms of a pus producing organism which has
invaded a part or the whole of the seminal tract. In the ambulatory patient
we are very often dealing not with a specific urethritis but with a urethro-
vesiculitis and often an epididymitis.
A familiar character to all of us is the unfortunate worshiper with his
syringe and pet injection with the usual instructions to shoot until all am-
munition is exhausted while the gonococcus is retreating to the posterior
urethra, seminal vesicles, and thence to the epididymis where he can safely
"dig in" for the winter. Once securely entrenched in one of his favorite
habitats he little fears the barrage of drugs which are usually thrown upon
him.
The gonococcus having suddenly and safely arrived in some portion of the
epididymis it produces the most painful and troublesome complication of
gonorrhoea, the symptoms of which are too well known and classic to enu-
merate in this discussion but if the treatment of this condition is an index
to the pathology produced surely few of us have given the latter serious
consideration or study.
A few points of interest in the pathology incident to gonococcal infection
of the epididymis may not be amiss, first, the infection is both proliferative
and destructive; second, abscess formation in some part of the epididymis
is not the exception, but the rule ; third, the tunica vaginalis is generally in-
flamed and is the seat of acute inflammatory hydrocele ; fourth, in case of
long standing the pathology is very similar to that seen in gonococcal infec-
tions of the fallopian tube.
While the surgical treatment of gonorrhoeal epididymitis is now gener-
ally accepted the usual treatment is palliative and expectant rather than
surgical as was intimated in the early part of this paper. Rest in bed, the ap-
plication of heat and cold, guiacol and ichthyol are too well known to discuss
here.
In our army in France epididymitis was frequently a complication of gon-
orrhoea. In my opinion, more frequent than in civil life for two reasons, —
first, because many were inducted into the army through the draft with
chronic gonorrhoea who after long hikes with full pack would suddenly go
down with acute epididymitis ; and an extension of the infection from an old
infected vessicle. I should like to term this class gonorrhoeal carriers. Sec-
ond, soldiers who contracted acute gonorrhoea were required to perform
the arduous duties of a soldier which kept the urethra and perineum muscles
in motion, a prominent, predisposing factor of posterior urethritis.
The surgical treatment which was so acceptable and practicable for the
military surgeon was epididymotomy. The object of this paper is not to
bring you anything new but to commend this operation to you as worthy
of trial and advocate it in selected cases of gonorrhoeal epididymitis, both
acute and recurrent. This operation will insure a shorter convalesence
(from three to five days in hospital) than the expectant treatment, with im-
mediate relief of pain.
132 NORTH CAROLINA MEDICAL SOCIETY
A slight modification of the operation described by Hagner of Washing-
ton, D. C, gives splendid results. The testis is held firm and rotated on its
upper pole ; an incision one-half to t\yo inches in length is made down to the
tunica vaginalis ; the scrotal contents, having been delivered, the tunica vagi-
nalis is opened and the contents of the accompanying inflammatory hydrocele
is evacuated. The epididymis is now in plain view. It is examined and at
some selected point is opened with catract knife. A Hagedorne needle is
introduced and the point of suppuration sought for. Drainage, of prefer-
ence, is instituted. The incision is enclosed in the usual manner, silk worm
gut sutures are better left long, as in repair of the perineum, collodion dress-
ing applied with suspensory or adhesive shelf as support.
CONCLUSIONS
1. Epididymotomy is the logical treatment in the majority of cases of
gonococcal infection of the epididymis, because this operation is based on
pathological findings which are essentially surgical.
2. By the immediate relief of the severe pain the patient is rendered
comfortable and convalescent is much shorter than in cases which are treated
locally.
3. A very small per cent recur, while the surgeon has the advantage
of being able to treat the posterior urethra almost immediately after oper-
ation.
4. By the relief of tension in the early stage of the infection the prospect
of sterility is minimized.
5. Early operation (within the first three or four days after the present-
ing symptoms) will afford the best results.
6. In recurrent infections of the epididymis you not only can remove a
troublesome focus but in epididymotomy we have a valuable asset in pre-
venting sectual neurasthenia.
DISCUSSION OF DR. MCKAY's PAPER
Dr. Addison G. Brenizer^ Charlotte: This paper was very pains-
takingly prepared and a very good paper, but on a subject about which I do
not know much. I failed to understand something that Dr. McKay said
about presenting the testicle and using the Hagedorn needle. The paper
was most excellent and I would be glad if he would explain more clearly.
Dr. McKay^ closing the discussion: This operation can be done in one
of two ways. In Dr. Hagner's original operation he opens the tunica vag-
inalis and exposes the whole epididymis. Usually you can locate the point
of suppuration. This point is then opened preferably with a cataract knife.
Often the abscess is very small. The largest I have seen I suppose would
contain about half a dram of pus.
The other method is simple. A small incision is made through the cap-
sule of the epididymis, a hagedorn needle is introduced and the point of
suppuration sought for.
I appreciate Dr. Brenizer's discussion of the paper very much. While I
am on my feet I would like to mention that Dr. Vincent, of Tampa, Flori-
da, who has a very skilled method, simply injects novocain and uses the
SURGERY 133
cautery. He failed to explain satisfactorily to me how to use the cautery,
to evacuate the inflammatory hydrocele, but said it was an easy matter to
empty the hydrocele after opening the epididymis. The inflammatory
hydrocele causes much of the pain. In fulminating cases, produced by the
gonococcus, we practically always have a hydrocele.
Gynecology and Ob^etrics
The meeting was called to order at 10 :00 o'clock A. M., April 21st, 1920.
by the Chairman, Dr. J. M. Manning, Durham, N. C.
The section on gynecology and obstetrics will please come to order. I
was very much in hopes that we would have a larger audience here on ac-
count of those who have prepared papers, including myself. The first paper
to be presented in this section is "Some Phases of Obstetrics," by the
Chairman, Dr. Manning, and I will ask Dr. B. L. Long to take the chair
for a short while.
SOME PHASES OF OBSTETRICS.
Dr. J. M. Manning, Durham, N. C.
It is said that Hippocrates, the great Grecian doctor, after finishing his
wonderful work on the Practice of Medicine, proclaimed to the ancient
world that "he had written every thing that was known about medicine or
ever would be known."
The first part of this statement we can admit ; but the wonderful develop-
ment and the great scientific discoveries that have been made since the days
of the ancient writer prove the falsity of his prophecies, except perhaps in
the field of obstetrics, because a child's advent into the world is the same
now as it was then.
As chairman of this section I invited a specialist to prepare a paper on
obstetrics for this meeting, thinking perhaps that he might furnish some-
thing out of the ordinary, but he respectfully declined ; saying that he had
nothing new about which to write. So I shall undertake, with some mis-
givings it is true, to present a few thoughts which have come to the writer
during a period of thirty-five years spent in the general practice of medicine.
In so doing I am painfully aware of the fact that my experience in the
practice of obstetrics is similar more or less to every other practitioner in
the society, and I do not presume, nor can I say anything on this subject,
which will furnish one spark of information to any of you.
Since Adam and Eve were sojourners in the garden of Eden and were
not ashamed of the scantiness of their dress until Eve tempted did eat of the
apple and passed it on to our distinguished ancestor, practical obstetrics be-
gan in the world and has been peculiarly active in all ages and among all
people, civilized and uncivilized, jew and gentile, cannibal and cocanut
twirler ever since. It is true that there are a few notable exceptions to the
general rule, for we are told that Eve the mother of all had no mother her-
self, but the Lord God caused Adam to fall in a deep sleep, and from one
of his ribs made woman. In the year Anno Domini 1920, Adam's lost rib is
the most important part of his anatomical frame, for this rib is gaining much
distinction in the industrial and political world, and when the suffragist
amendment becomes a law this rib will become a shining mark for the poli-
tician's gun-fire.
There is another gentlemen who took a distinguished part in the activi-
ties of life in his generation and in whose honor and in commemoration of
the manner of his coming the medical profession has christened that oper-
GYNECOLOGY AND OBSTETRICS 135
ation, which in this year of surgical progress is becoming more and more
popular and less and less dangerous to the mother and child, commonly
known as Caesaran section, on which our friend, Doctor Woodard, will
speak today.
So far as we are informed the remainder of the citizenship of the earth
has been ushered into life in the usual way. It is not my purpose to impose
on your patience a text-book dissertation on obstetrics, but to those who
through lack of experience have not had the opportunity to develop any
methods of their own, I respectfully refer them to such distinguished au-
thors as Hirst, Williams, and Wright, who have so forcefully given detail-
ed procedures in the management of cases of labor — before, during and
after parturition. I might say this, it is well, when engaged to care for a
pregnant woman, and subsequently to attend her in confinement, if a primi-
porae, especially, to see that her pelvic measurements are sufficient to nor-
mally give birth to a child at full term. I would suggest that her diet be
somewhat restricted as to the ingestion of red meats, and that she take a
fair amount of out-door exercise and that her emunctives be kept in a
healthy condition. Urinary analysis should be made at intervals of two or
three weeks after the first half of gestation, and oftener if found necessary.
If these preliminaries are satisfactory to the accoucheur there is abundant
assurance that there will probably be a normal labor, but unfortunately
for the medical attendant and likewise the patient there will be no positive
assurance there will not be some serious emergency to arise at the time of
parturition which will greatly disturb the doctor's composure of mind and
at the same time throw the family of the patient into violent consternation.
For instance, there may follow delivery a concealed hemorrhage with no
outward evidences of such a serious complication. The patient complains
of blindness, her face is blanched, her respiration is difficult and gives other
evidences of a rapid disintregration. In an emergency like this the accouch-
eur begins to perspire and as the condition grows more serious the more
active his sweat glands, until his face is bathed in a profuse perspiration. He
realizes he must do something and do it quickly and he has no time to re-
call what obstetrical authors may suggest as the proper procedure. He must
check this flow of blood or else see his patient fade away like a flower under
the burning rays of a July sun.
The writer has had several experiences of this nature and so has every
other doctor who has done much obstetrical work. Let me say to the young
members of the profession in emergencies of this kind, don't lose you head,
for the family of the patient will do this for you. Look wise no matter
how agitated you may be on the inside, don't let this disturbance come to
the surface. Never lose confidence in yourself. The important thing to
remember in concealed hemorrhage is to empty, with your hand, the uterus
of its blood clots so that this organ can normally contract and check the
bleeding. Administer hypodermically ergot or pituitrin. Give stimulants,
enteroclysis, or hypodermoclysis of normal saline solution, and last but not
least hold your hand over the uterus until you know beyond a doubt that
this organ is well contracted ; then perhaps the mentally and physically ex-
hausted accoucher can rest from his labors with the consciousness that the
136 NORTH CAROLINA MEDICAL SOCIETY
life of his patient has been saved and his reputation, for there is no death in
the community so sad and so ruinous to the hopes and aspirations of the
doctor as that of a woman in confinement.
Picture, if you please, this scene — a country home, a woman in confine-
ment a lone doctor with no trained assistance, and no available medical
help, and an emergency as I have described — then this other scene in con-
trast: — a city physician (the man who writes learned text-books on obste-
trics) a hospital, or a private home, two or three trained nurses, a medical
assistant, everything to be used about the patient previously sterilized. His
gown and gloves and his assistants' paraphernalia carefully prepared and at
the conclusion of the ceremony an obstetrical fee that would make the
country doctor smile the balance of his natural life. This is a striking con-
trast, but yet it is absolutely true. What experience has the latter with the
former and how can he better overcome difficulties.
There is still another complication we sometimes meet in obstetrical
work.
PUERPERAL ECLAMPSIA
The learned authors tell us that this condition follows a deficiency of
urinary execretion, or rather a failure of the kidneys, and other execretory
organs to properly eliminate the excrementitious products of the system.
Toxaemia of pregnancy is a pathological condition produced by pregnancy,
and which is generally relieved after the termination of parturition. The
symptoms which generally appear during the second half of pregnancy are
edemas of the extremities ; urinalysis shows albumen, casts both white and
red corpuscles. Unless this condition is relieved by treatment — medical,
dietetic, and otherwise eclampsia is apt to follow.
Albuminuria in the early months of gestation, is indicative of either
chronic or acute nephritis and is not necessarily followed by eclampsia, but
this condition occurring in the seventh, eighth or ninth months of gestation
is usually due to a general toxaemia associated with toxsemic kidneys. Under
these conditions we may fear convulsions at the end ot gestation because
the system is poisoned by toxins resulting from imperfect elimination due
to defects in the functioning of the intestines, liver, and kidneys.
The health of an individual is precarious at best : — He may be well today
and sick tomorrow. We are often called to see a patient suffering with
headache, high fever, coated tongue. We tell him that he has a bilious at-
tack for lack of a better name. We give him calomel at night to be follow-
ed by a dose of epsom salts in the morning. The next day he is well. This
man had an intestinal toxaemia, which has been relieved by flushing the
sewer pipes and eliminating the poisons he has developed within himself,
either through the ingestion of food, or defective tissue metabolism induced
by the improper functioning of the organs of secretion and elimination.
This equilibrium of health appears to be more easily disturbed during preg-
nancy than at other times. It is the disturbance of the balance between the
production of toxins and their elimination. This condition in the pregnant
woman is more serious because she must eliminate the poisons accumulated
by herself as well as those of the growing fetus in utero and it is this condi-
tion that is followed by eclampsia. As a remedy I would suggest an abund-
ance of epsom salts. Clean out the intestinal tract, eliminate thoroughly
day by day.
GYNECOLOGY AND OBSTETRICS 137
I might go on if time permitted and tell of other serious emergencies that
might arise in the practice of midwiferj^ that would jolt the doctor, the pa-
tient, and the family but what is the use. The older practitioners have seen
them all and the younger graduates of medicine as he pursues his weary way
will in time meet them on the roadside. It will be up to him to make the
most of them.
In conclusion, let me say that the life of the country obstetrician is a hard
one, Hlled with doubts and uncertainties, headaches and heartaches. His
reward will not be in dollars and cents, for the surgeon in one hour's work
will receive many times the obstetric fee, but in the consciousness that he
has done what he could to alleviate the pains of a woman in travail.
Dr. B. F. Long: Is there any discussion of this paper?
Dr. Manning, taking the chair: Now, gentlemen, is it the disposi
tion of the members here today to discuss these papers as they are read or
wait until all papers are read, which is not many, and have the general dis-
cussion afterwards? If the chairman doesn't hear a motion to the contrary,
we will have the papers read first and the discussions later, because they are
all correlated subjects. No objection, so ordered.
CONCERNING THE DISEASES OF THE CERVIX UTERI.
Dr. Foy Roberson, Durham
Many interesting papers have been written on csserean section, uterine
suspension, perineorrhaphy and other g>^necologic problems, but very little
has been written concerning that part of the internal genitalia of the female
which bears the brunt of most gynecological pathology. I refer to the cervi-
cal portion of the uterus. Indeed the cervix is the portal of entrance of prac-
tically all pelvic diseases.
From the time the young girl enters the age of puberty until she has passed
the menopause, the cervix is constantly in danger of succumbing to any
of the pathologic conditions of which it is susceptible, and these are many.
In passing, I will mention some of the most common ; congenital cervical
atresia, partial stenosis from acute antiflexion, atresia due to scar tissue, lac-
erations with subsequent hypertrophy, erosions and eversions of the cervical
mucosa, endo-cervicitic, cystic degeneration, cervical polypi, chancre of the
cervix, tuberculosis of the cervix and finally that most malignant of condi-
tions, cancer of the cervix uteri. It will be observed many of the above con-
ditions have their origin in childbirth or the venereal infections. Personal-
ly, I believe that cancer of the cervix is always due to either the results of
childbirth or infection of some source. I have never seen a cancer of the
cervix without a previous history of one or the other or both of these condi-
tions. In other words, I have never seen a cancer of the cervix without a
history of either laceration or endocervicitis. It therefore behooves us as
medical men and surgeons to give more consideration to this part of the fe-
male anatomy in order that women may be saved from some of the dangers
of developing malignant disease, also that they may be saved much un-
necessary suffering. There is probably no more annoying condition than for
a woman to be constantly troubled with a foul irritating leucorrhea which
is practically always present in any cervical disease. Again it is not infre-
quent that menrorrhagia has its direct origin in some pathological condition
138 NORTH CAROLINA MEDICAL SOCIETY
of the cervix. Not only may leucorrhea and hemorrhage be present, but
sooner or later the individual becomes intensely nervous and complains of
backache, loss of appetite, loss of weight, and ill health in general and finally
if the condition is not relieved, there is great probability of the development
of carcinoma as a result of a thing that was previously benign. Even at
childbirth, a woman may bleed to death as a result of a laceration of the
cervix opening into the uterine artery, and quite frequently puerperal septic
infection enters through a lacerated cervix.
What then is to be done in order that such cases may be prevented from
occurring or that they may be relieved after they do occur? First of all, the
medical profession should do everything possible to co-operate with the
campaign now being waged against venereal infection. I am sure that great
good can be accomplished in this way toward preventing the specific diseases
of the cervix. I also think that every woman who is^delivered in a hospital
or under such conditions that would justify such a procedure, should have
a careful inspection of the cervix after delivery and should laceration be
proven it should be repaired immediately. In this way we may possibly pre-
vent a subsequent development of hypertrophy of the cervix with its accom-
panying erosions and leucorrhea, and possibly at the same time forestall an
impending puerperal septic infection with its deadly results.
I feel, too, that quite frequently the physician or surgeon fails to examine
carefully the cervix in the ordinary gynecological examinations thereby
overlooking important pathology, probably because he gives his entire at-
tention either to the perineum or to the uterus, tubes and ovaries. And even
when disease of the cervix is known to exist as well as disease of other
female generative organs, it seems to me that too frequently we are not will-
ing to spend the necessary time in giving it the attention it really needs.
Probably a beautiful hysterectomy or perineorrhaphy is done and the dis-
eased cervix is left behind to cause the usual train of symptoms and possibly
to develop later into carcinoma. I have seen carcimona develop in two
patients who had never borne children. In one a bilateral salpingo-ospho-
rectomy had been done for tubo-ovarian disease and the other had a supra-
vaginal hysterectomy for pelvic inflammatory disease. In all probability the
carcimona in these cases was produced by the constant irritation of a leu-
corrhea of long standing which had its origin in an infected cervix which
was most likely a specific infection to begin with. I believe that if the cer-
vical mucosa in these cases had been destroyed at the time of operation by
the electric cautery or by excision, that malignant disease would never have
developed and that these patients would have been saved much suffering
before it did develop.
It has been my custom for several years in doing partial hysterectomies to
first destroy the disease of the cervix with the electric cautery. True, it is a
little troublesome and time consuming, but it is certainly time well spent
and productive of much good, for the patient is practically always relieved
of a troublesome leucorrhea and I have never seen cancer develop in such
cases.
Last year at the State Medical Meeting, Dr. Heineberg of Philadelphia
read before this section a most interesting and instructive paper on the medi-
cal treatment of the disease of the cervix uteri as a preparatory procedure to
GYNECOLOGY AND OBSTETRICS 139
either amputation of the cervix or trachelorrhaphy- He showed that much
could be accomplished in treating the hypertrophied cervices with lacerations,
erosions and eversions by medical treatment. In about 50% of his cases,
he was able to relieve the condition entirely by medical treatment. The
other 50% required amputation or trachelorrhaphy, but always in a more
modified degree than when no treatment had preceded operation. His treat-
ment consisted in first cleaning away the secretion with a weak alkaline solu-
tion, and then the application of silver nitrate solution. The silver was
first used in 50% strength and later decreased to 10% strength. He also
brought out in his paper that trachelorrhaphy was always to be preferred to
amputation in women who are still in the child bearing period since about
50^ of the women who became pregnant after amputation of the cervix
aborted.
I do not think there is any place for the curette in treating these condi-
tions. It probably does much more harm than good. I mention this because
1 know that quite frequently a curettage is done for leucorrhea. The
treatment should be either medicinal applications or operative such as am-
putation, trachelorrhaphy, or the electric cautery.
Let me say finally that I believe all women as they approach the mena-
, pause should have thorough pelvic examinations made and that any existing
disease of the cervix should receive proper attention. In this w^ay many
cases of cancer may be prevented.
TO SUMMARIZE
1. Diseases of the cervix uteri are many and are frequently present.
2. It should be routine in gynecological examinations to make a thorough
examination of the cervix, and the treatment proper should be given.
3. Wherever such disease is found to exist and supra-vaginal hysterec-
tomy is indicated, the cervical mucosa should either be exercised or destroyed
4. Medical applications are splendid, especially preparatory to opeartion,
and frequently they m?.ke operation unnecessary.
CESAREAN SECTION IN ECLAMPSIA.
C. A. WooDARD^ Wilson, N. C.
Eclampsia always constitutes a condition of emergency. It is a culmina-
tion o'f the effects of toxic influences that at the time of the seizure have al-
ready been poisoning the system for weeks or months. Throughout the
pregnancy the patient may show symptoms of the disease which give ample
warning of the danger to be encountered, or the explosion may come wholly
unannounced, as instanced by a case of mine, which manifested no symptoms
— no swelling, no headache, no eye symptoms, passed a negative physical
examination and exhibited a normal urine as late as 24 hours before the
attack.
The toxins, whatever their origin, not only circulate in the blood but at-
tack the various organs of the body, notably the liver, the kidneys, the bram
and the lungs. The liver presents the most interesting pathology. At
autopsy there are found spots of necrosis — hemorrhagic and anemic — there
may be cloudy swelling or even general autolysis. The picture is sugges-
140 NORTH CAROLINA MEDICAL SOCIETY
tive of that of acute yellow atrophy of chloroform poisoning. The brain
shows oedematous areas and anemic spots with occasional hemorrhages and
areas of softening. The kidneys show varying degrees of nephritis, the par-
enchymatous type predominating as a rule. The lungs are congested and
At times oedematous with thrombi and emboli here and there. The pneu-
monia that sometimes intervenes is a complication and not a part of the dis-
ease per se. The oedema is the clinical manifestation most evident in some
cases.
One cannot examine these organs without wondering how the patient
lived with so much destructive pathology, for of course it is inconceivable
that these necrotic areas and degenerative changes could have developed
after the convulsion. And such pathological changes explain why the con-
dition is still so resistent to treatment and enables one to understand why
even the most reputable methods of eliminative treatment fail in a certain
percentage of cases to check the progress of the disease. The toxins destroy
the tissues of vital organs, and as in the instance of the brain, enter into
combination with the cells, so that the elimination of the toxins from the
blood only gets rid of a part of the poison and leaves the patient still suffer-
ing from the damage already done to the cells.
It is interesting that the disease displays a variation in the predominance
of involvement of the several organs, the symptoms giving a clue to the
particular type according to the degree of involvement; that is, one case
will show a predominating kidney involvement revealed by the urinary
findings, another will show by the nervous and mental symptoms that the
nervous system is the seat of the greatest amount of damage, another that
the lungs are attacked as evidenced by the symptoms and signs of pulmonary
oedema, still another will be jaundiced revealing severe disease of the liver.
All these organs are involved, but in varying degrees in different cases.
These points are of importance in management of the individual cases.
As to the treatment of these cases, it is pretty generally agreed that the
uterus should be emptied as soon as possible, though Stroganoff's expectant
method has its advocates, especially for cases so situated as not to have ac-
cess to surgical treatment.
In cases in which labor is well under way and dilation of the cervix is
sufficiently advanced version or the application of forceps is rational surgery,
but if the eclamptic seizure takes place before labor begins when the cervix
is not dilated, or if the passages are contracted or any other obstruction ex-
ists to prevent easy instrumental delivery, and the patient is not infected, I
think Ceasarean section is indicated.
The operation is simple and is attended with less shock in this class of
cases than version or the use of forceps, and certainly the child has a much
better chance for being delivered alive. Anaesthetics are uhjectioiiable, but
it requires little more for a section than for a version or instrumental de-
livery. Indeed it often takes less time for a section, and if morphine and
hyoscine are administered before beginning the (ipe.-atica, one is able to get
through with very little anjEsthetic. The amount of traumatism in Cesa-
rean section is less in many cases, and if the operation is performed with
reasonable dispatch it is attended with very little additional shock.
Several types of operation have been devised, as the extraperitoneal and
GYNECOLOGY AND OBSTETRICS 141
the Porro operation for septic cases, but in the purely eclamptic cases that
have not been examined too much the simple transperitoneal operation is
most suitable.
The usual preparations are made for an emergency abdominal operation
and the bladder is emptied. An incision is made from a couple of inches
above the umbilicus to three or four below, the uterus is delivered or not as
the operator may prefer. If the uterus is delivered a towel should be spread
over the abdominal wound to protect the intestines or prevent contamina-
tion with the uterine contents. It sometimes facilitates matters to clamp
the skin together with forceps behind the uterus. An incision is made
through the uterus from the fundus down the mid-line for from four to
six inches, the child is delivered, the cord divided between clamps, the pla-
centa delivered and the uterus wiped out with gauze. Pituitrin may be
administered hypodermically before the uterine incision is made but usually
the uterus contracts sufficiently without it. An assistant's hands around
the cervix controls bleeding until the wound is closed.
The closure of the uterine wound is an important step in the operation,
as indifferent closure may allow insecure healing and predispose to rupture
in subsequent labors. It is essential to coapt the sides of the wound snugly
and to draw the sutures taut. Various methods of suture are used. My
preference is for closure with three layers of running sutures, using No. 2
chromic catgut for the deep layers and No. 1 for the peritoneal layer. The
first includes the deeper half of the muscle down to the mucosa, the next
takes in the rest of the muscle layer up to the peritoneum and the third
brings together the peritoneal layer. It is important that the sutures be ac-
curately applied and that the knots be tied securely, and that the peritoneum
be coapted perfectly to prevent adhesions. Occasionally an interrupted
stitch here and there will be necessary to prevent ooze. The omentum
should be drawn down behind the uterus, and the abdominal wall closed in
the usual way.
The post operative treatment is the usual after abdominal operations plus
the eliminative treatment for the eclampsia — morphine and hyoscine for
the nervous manifestations, purgatives and diuretics to induce elimination
and alkalies to overcome acidosis. In some cases phlebotomy is a most valu-
able aid. I do not care for sweating as it makes the patient restless^ and
likely does as much harm in this way as it does good by the small amount of
toxic matter eliminated.
I do not wish to be judged as advocating Csesarean section as a routine
in eclamptic cases, but in selected cases I am of the opinion that it is a treat-
ment of choice, for it frees the child from the hazard of delivery and is at-
tended with less shock and traumatism to the mother.
OVARIAN TUMORS.
Dr. John B. Nicholson, Worthington
During 16 years of surgery and general practice, perhaps the gynecological
thing that has come to me most frequently, except minor conditions such as
lacerations, etc., has been ovarian tumors. This, while a condition that
yields readily to surgical procedure, is distressing, when encountered in ig-
142 NORTH CAROLINA MEDICAL SOCIETY
norant whites and negroes. Frequently have I had patients, sufferers for
years, brought to me in extremis because of ignorance and prejudice.
About ten years ago a negro woman, 42 years of age, enormously dis-
tended, came to me, she could hardly breathe. She had waited eighteen
months for the delivery of a child. Upon opening the abdomen we found
a large cyst-adenoma, (multi-locular glandular cyst). This growth was
very adherent to the parietal peritoneum. This is a large and common va-
riety of ovarian cysts. These cyst masses are filled with a gelatinous stuff,
which at times leaks and spreads over the intestines, giving the appearance
of malignancy. There was no leakage in this particular case. It is well
however, to say when rupture of this type of cyst does take place that the
cells inside the cyst continue to secrete this gelatinous material in large
quantities- The cyst should be removed and as much of the gelatinous
material as possible. Nothing can be accomplished by washing out the ab-
dominal cavity.
Dermoid cysts of the ovary have been rare to me. We have had only
two. One a large cyst of the left ovary in a white woman, 45 years of
age; this cyst contained hair, in large quantities, very long and could be
combed, some teeth and sebaceous material. The other dermoid was of the
right ovary in a white girl, 15 years of age. This contained a small
amount of hair and much sebaceous material. Both of these cysts were
above the average in size. In children and young girls these tumors are at
times extremely malignant, recur rapidly and terminate fatally; these are
teritoma. Dermoids also leak and a remarkable case has been described
in which so much sebaceous material had leaked into the abdominal cavity
that the abdomen pitted like soft clay. Quite a number of cases have been
reported in which, when the surgeon opened the belly, the peritoneum was
found covered with nodules, from which grew tufts of hair. These "epithe-
lial weeds", as they are called, differ from cancer nodules, in that they do
not invade the underlying tissues.
We have seen one fibroid ovary. This operation was not done for the
ovarian condition but for the removal of what was thought to be a large
fibroid uterus. This fibroid uterus proved to be a very large malarial spleen,
(twelve and a half pounds) which had descended and was resting on and
adherent to the uterus. The spleen was removed, also the fibroid ovary,
whi(5h was not very large but about the size of an orange. The patient is
living. This operation was done fourteen years ago so there was nothing
sarcomatous about this fibroid ovary. These fibroid tumors undergo degen-
erative changes as do uterine fibroids, they become cystic and calcify- They
are found in the young and the old.
We have never seen a sarcoma of the ovary, unless the dermoid cyst in
the girl fifteen years of age proved to be one. This removal was done such
a short time ago that I am unable to say as to its malignancy. I have no
pathologic report on this growth. Bland Sutton has collected one hundred
cases of cystic ovaries in girls fifteen years and under. Of this series forty-
one were simple cysts, thirty-eight simple dermoids and twenty-one sarco-
mas. This is perhaps too small a percentage. He says that sarcoma does oc-
cur more often, as it does in other paired organs.
Papillomatous cysts are not so rare, but are very puzzling the first time
GYNECOLOGY AND OBSTETRICS 143
one encounters this type of growth. The first impression is, that the thing
is malignant, that all to be done is close the abdominal cavity because while
in the early stages the papillomatous processes are confined inside the cyst
wall, the cyst wall soon ruptures and tumor resembles a huge cauli-flower,
with the warts spreading out over the entire peritoneum. Hydro-peritoneum
is also present, due to peritoneal irritation. This is a hopeless picture.
However, the removal of the growth, in most instances, can be done with
good results. One case recorded by Pye Smith, at Guy's Hospital, London,
a woman was tapped 299 times between August 18th, 1884 and April, 1894.
She came for the three hundredth tap and died. The post-mortem showed
a papilloma of both ovaries, which could have been relieved by operative
interference. On the other hand these tumors will sometimes attain an
enormous size without bursting.
We' have never encountered a carcinoma of the ovary. These growths
are secondary to cancer of the gastro-intestinal' tract or gall-bladder. So
these are metastatic or implantation cancers. The cancer cells invade the
adjacent tissues and become grafted on to the cystic ovary. The primary
focus should, of course, be looked for whenever we encounter a growth of
the ovary with carcinomatous appearance.
Cysts of the broad ligament. We remember quite a large one, as large
as a medium size watemelon. These cysts are found between the anterior
and posterior folds of the broad ligaments and contain simple fluid. They
can be enucleated easily, care being taken to avoid injury to the uterus. At
times much oozing hemorrhage attends this operation, then it is best treated
by marsupialization.
It is known now that hydatid cysts, slow effusion of blood, tuberculous
exudates, and ovarian cysts sometimes will become enclosed in a fibrous tis-
sue capsule formed by the exudate from the peritoneum, which their pres-
ence excites. These are known as Spurious Capsules and are often mislead-
ing, however, we can remember that true ovarian cysts always project from,
never inside, the broad ligament.
Cystic growths are pedunculated usually and sometimes undergo axial
rotation, producing symptoms analagous to strangulation of the intestines,
minus foecal vomiting and this may even take place confusing us in the di-
agnosis. When cysts suddenly enlarge and give symptoms of axial rotation,
if no rotation be found on opening the abdomen, then we usually have free
intra-cystic bleeding.
Sometimes when opening the abdomen the cyst is found to be suppurating.
It is hard to understand this rare condition, since the cyst is air tight. We
know that the chief sources of infection are the tubes, intestines, vermiform
appendix, tapping and puncture by foreign bodies. Bland Sutton reports a
suppurating cyst due to puncture by a fish bone through the rectum. The
cyst was behind the uterus and adherent to the rectum. The blood stream
is also undoubtedly a source of infection in systemic diseases, as is evidenced
by reported cases of suppurating cysts, due to the typhoid bacillus. This
organism has been isolated from such cysts in many instances.
144 NORTH CAROLINA MEDICAL SOCIETY
"THE TERMINATION OF PREGNANCY FOR THERAPEU-
TIC REASONS."
Dr. F. Webb Griffith, Asheville, N. C.
In this brief paper I shall not discuss those cases where the uterus is emp-
tied for an inevitable abortion, missed abortion or dead foetus, but only that
group of cases where the pregnancy is terminated before term out of con-
sideration for the health or life of the mother. Criminal abortion, whether
done to avoid disgrace or simply to limit the size of a family we all con-
demn. Still more severely do we condemn the physician who violates the
confidence and trust placed in him by the state, by doing a curettement
under the deceptive diagnosis of "endometritrus" or "dysmenorrhea" when
in reality he is knowingly doing a criminal operation. When a curette-
ment at the patient's home is discouraged by the profession and when all
scrapings obtained at the hospital are examined routinely by the hospital
pathologist, such practice will automatically cease. There comes occasion-
ally to every physician and frequently to those of us who do gynecology,
the necessity for deciding whether or not the life of the foetus should be
sacrificed in the interest of the mother. During the four years from Janu-
ary, 1916 to January, 1920, my records show that pregnancy was termi-
nated before the viability of the child in twenty-five cases. An analysis of
these cases I shall use as the basis for this paper. In every case there was
at least ohe and usually two consultants who kindly shared the responsibili-
ty with me. In eleven of these patients the indication was pulmonary tuber-
culosis.
In a health resort like Asheville it is not surprising that pulmonary tu-
berculosis should head the list of causes for therapeutic abortion. Just what
is sufficient indication to justify emptying the uterus in a tuberculous patient
is still a much mooted question. You will see one patient who has appar-
ently only a slight lesion, and that well arrested, pass through pregnancy
nicely, and then after labor rapidly go to pieces, either by a flaring up of
the pulmonary lesion or by a general miliary tuberculosis. On the other
hand one with an advanced lesion can occasionally go through without ap-
parently doing much damage. I believe we are perfectly justified in these
cases, in giving certain amount of weight to the wishes of the patients
themselves. Where a woman has two or three children we are not quite
as much justified in taking a chance with her health and possibly her life by
allowing pregnancy to continue as we would in a childless couple anxious
for offspring, especially if they are willing to accept the risk after it has
been fully explained to them.
Some of my good friends, whose opinions upon pulmonary tuberculosis
carry great weight, maintain that we are not justified in terminating preg-
nancy more than once upon the same patient. They tell their patients that
pregnancy has been terminated in the interest of their health or life, but
should they become pregnant again they do so at their own risk and must
go to full term and bear the consequences. That attitude I cannot quite
understand, for, if it is the duty of the medical advisor to safeguard them
the first time why not the second time? That is like saying to a patient,
who has by indiscreetly getting wet or chilled developed pneumonia, that
all medical skill would be used to save him this time, but that should he
GYNECOLOGY AND OBSTETRICS 145
commit the same indiscretion again he must suffer the consequences without
the help or alleviation the physician might be able to give. To me the more
rational procedure would be to say to the patient that should she become
pregnant again, we will terminate pregnancy, only however, upon the con-
dition that we be allowed to go a step further and sterilize her. Some of
these patients are young and while at the time not in shape to go through
a pregnancy, yet it is possible that a few years later they may be so improved
as to be perfectly justified in taking the risk. In such cases instead of domg
the usual ligation and cutting of the tubes, it would be wiser to employ
some of the methods which aim at temporary sterilization.
The technic described by Carey Culbertson in 1917, appeals to me more
than any other I have seen. It consists of a high abdominal incision, start-
ing just beneath the umbilicus and extending downward. The uterus is
caught with uterine forceps and brought backward toward the promontory
of the sacrum. The left round ligament is then caught about 6 cm. from
the uterine horn and lifted up. A forceps is then passed through the "clear
space" of the broad ligament from before backwards and the fimbriated ex-
tremity of the left tube brought into the anterior cul-de-sac and stitched
with a fine catgut suture. The right tube is then treated the same way.
Beginning at the point where the left round ligament passes into the left
inguinal canal the round ligament is stitched with continuous catgut to the
anterior parietal peritoneum down its entire length to its junction with the
fundus. The same is done on the opposite side. A fold of the anterior par-
ietal peritoneum is now brought across the fundus from one round liga-
ment to the other.
This procedure leaves the tubes patent and opening into a small cul-de-
sac completely shut off from the rest of the abdominal cavity. Culbertson
performed this operation thirty-one times, but unfortunately has not yet
had occasion to "unsterilize" any of the patients. So that while it is very
pretty theoretically it may not work out so nicely in practice. However, it
gives the patient hope that some day she might be in shape to become preg-
nant and she does not have that mental depression which sometimes follows
when a woman realizes that she is permanently and irreparably sterile.
For the pernicious vomiting of pregnancy, operation was done eight
times. These cases were all given treatment by their family physician be-
fore being brought to the hospital and in some cases where the condition
was not too desperate on admission treatment was continued in the hospital.
We have been guided entirely by what seemed to be the condition of the
patient rather than by the estimation of the nitrogen output as advocated
by Williams. When the patient is anxious for a child and will give her
full cooperation in the treatment it is surprising what can be accomplished,
even in the most desperate cases. When, however, the patient strenuously
objects to the discomfort and treatment and to any further increase of the
family the physician has a most difficult task. If he has not the cooperation
of the patient and the moral support of the husband to make at least a rea-
sonable fight, he should drop out of the case.
Caesarean section, placenta prsevia or the toxemia of pregnancy after the
seventh month are not considered because they do not decrease, but rather
increase the chances of the child and therefore do not come in the scope of
146 NORTH CAROLINA MEDICAL SOCIETY
this paper. However, in one case of pre-eclamptic toxemia the child, al-
though born alive, died within twenty-four hours. The one case of eclamp-
sia which was at the six and one-half month was seen in consultation at a
hotel twenty miles away. The patient had been having convulsions for
twelve hours, numbering in all about twenty. As it was out of the question
to move her to the hospital, a room was hastily prepared and a vaginal
caesarean section done, after which she had only one slight convulsion and
made an uneventful recovery.
In only one case have I had to empty the uterus for a pyelitis, and that
was in a woman about five months pregnant. As a rule, passage of a renal
catheter and washing out the pelvis of the kidney suffices either to relieve
the condition or to tide over the patient until after labor. In this case, how-
ever, the patient was admitted to the hospital in such a desperate condition
that it was obvious radical treatment was urgently indicated. In one case
the uterus was emptied about the third month, for a progressive exophthal-
mic goiter. Following this patient was kept at rest until her symptoms im-
proved and then a thyroidectomy was done. In one case a five weeks preg-
nancy was terminated in a patient who had a short time previously been
through two major operations and had also had a rather severe hem-
orrhage from a gastric ulcer.
The last case of my series was a most interesting one. A girl aged four-
teen was brought to me with the history that for several months she had not
menstruated. Examination showed a general fullness of the lower abdomen
but no definite enlargement of the uterus could be outlined. Further ex-
amination showed what appeared to be a complete atresia of the vagina.
More careful search under an anaeesthetic revealed a small opening into the
vagina just large enough to admit the smallest sized probe. Upon enlarg-
ing the opening into the vagina a haematocolpos was encountered. After
cleaning out the blood clots the uterus was then felt to be enlarged. I nat-
urally concluded that we had also a haematometra, so I thoroughly dilated
the cervix and upon starting to remove the supposed clots from the uterus
I was surprised to find a pregnancy approximately three months. It was
then too late to do anything but proceed and empty the uterus.
In conclusion I again wish to emphasize the great responsibility which
these cases place upon the medical profession. We should call in as con-
sultants, those who are especially fitted to pass upon the disease for which
curettement is proposed. In that way the family physician and the gynecol-
ogist will be restrained from rushing into an operation for insufficient rea-
sons, or on the other hand, what is equally as culpable, will not allow a
patient to drag along, day after day or week after week, until irreparable
damage has been done.
DISCUSSION
Dr. Moir S. Martin, Mt. Airy, N. C. : This is an interesting series
of papers. The paper that I am especially interested in is the one on Cesa-
rean section by Dr. Woodard. The points in our work that I would espec-
ially like to call your attention to are: First, in regard to the anaesthetic.
In eclamptic cases the anaesthetic is a very important consideration. In our
work we use exclusively Gas and Oxygen. Of course in the majority of
cases the patient is given one-fourth grain of morphine and then it is some-
GYNECOLOGY AND OBSTETRICS 147
thing like thirty minutes to an hour before the operation is started. This
might cause some criticism because some of our best men contend that we
should not use opium in any form. Personally, we have used it and have
never seen any bad results following it. By this method your patient prac-
tically wakes up on the table, that is, if not too deeply unconscious from the
toxaemia, in other words, comes out from under the anaesthesia and you have
no bad results following your operation as you would in ether or chloro-
form. Gas and Oxygen in our opinion is the ideal anaesthetic in these
cases.
The second point, is the administration of soda and glucose solution by
the Murphy drip after the operation as a post-operative procedure, with
elevated bed or the Fowler position. This has been very satisfactory in our
work; at least we feel that it has helped us to overcome the toxaemia in
these cases. Those of us who have tried the alkaline solution in this class
of cases know that it is of benefit, as to how it does it that is another ques-
tion.
Dr. Lawrence, Winston-Salem, N. C-: In 1916 I read a paper be-
fore this Association on diseases of the cervix and vagina, and tried to point
out some of the dangers in these cases as a result of manipulation and oper-
ation. If we study the cytology of carcinoma of the cervix and vagina we
find that the cancer cell is a displaced epithelial cell. We start with the
normal epithelial cell, and as a result of irritation proliferation takes place
and goes on to the extent of breaking down the basement membrane and dis-
placing itself in the connective tissue when it becomes a cancer cell. This
is very simple pathology ; but the average text book on pathology is about
six or seven hundred pages, and when one begins to read the pathology of
cancer he soon becomes disgusted with it and puts the book back on the shelf.
McCarthyof the Mayo clinic has made the study of cancer quite simple,
and one who has read his works has been enlightened along that line.
In cancer of the cervix, I thoroughly agree with the paper that was read
on the etiology of it; that it is due to trauma, and the trauma may be pro-
duced in many ways, chief among which of course, is childbirth. Next we
may mention instrumentation et caetera, and an effort on the part of the
cells to repair the damage causes them to multiply in many numbers, and
for want of a better place than their normal location, they break down the
surrounding tissues and grow wild. Recently I have seen two very interest-
ing cases of carcinoma of the cervix that interested me very much. Both
of them happened to be in colored women, and they both happened to be
young women, one thirty-one and the other twenty-nine years of age. They
both had cancer of the cervix, both had had pelvic inflammatory disease.
One was operated on in Durham by a colored doctor and the other was
operated on in Winston-Salem by a colored doctor. I do not know what
was done in either case. I saw them about one year after their operations
and the cancer at that time was extensive, involving the cervix and vagina
and extending out into the broad ligaments on either side. I think there
is no doubt that these cases were caused by- trauma aided by infection and
should teach us a lesson in treating gynecological cases; that is we should
not handle the cervix or tissues any more than is absolutely necessary in
treating diseases of these parts. We should repair lacerations of the cervix
148 NORTH CAROLINA MEDICAL SOCIETY
and vagina at the time they occur in cases of obstetrics, if they can be done,
and it can be done in a hospital and in a majority of the cases in private
practice. There are cases, of course, remote from hospitals that cannot be
properly treated in these cases, I think they should be sent in as soon as pos-
sible or proper aid be given them at the earliest possible moment — that is
as soon after labor as possible. In repairing the cervix and vagina one should
be extremely careful to see that he does not turn in epithelial tissues in do-
ing the plastic work, in other words all tissues should be proximated evenly
and well.
Now all of us that do general surgery have complicated obstetric cases
sent to us for treatment; while I was intern in a hospital we had sixteen
vaginal caesarean sections and I do not remember how many abdominal sec-
tions. Since I have been out I have done something like twenty vaginal
caesarean sections, and about ten abdominal csesarean sections. I could not
give you the exact figures as to the number of cases or results obtained with-
out referring to my cases, but in general the results have been highly satis-
factory. In cases of eclampsia and placenta praennia I invariably do a Caesa-
rean section provided there is not sufficient dilatation and a pelvis that will
permit delivery by vagina. It is the most rapid and appears to be the most
rational way of delivering the woman. Every surgeon has a particular
technic of his own and if he gets good results from that technic it is the
thing for him to do. For instance, in regard to anaesthetics — in most cases
you do not give much anaesthetic, but I make it a rule if there is a com-
petent doctor around and especially an older man I ask him to give chloro-
form because it requires very little, it is most satisfactory in these cases, and
in my experience I have never seen bad results following its use.
After the operation I simply put them to bed and keep them warm, give
them plenty of fluids in the form of salt solution, glucose and soda solution
and treat the symptoms as they arise. In the last three cases I have had in
the past five months all three mothers and the children and even the father
have lived.
Dr. Woodard: Once in a while we see something as dramatic in medi-
cine as surgery. These cases of toxemia of pregnancy start out with
symptoms due to the pathology of the pregnancy, but owing to the inability
to retain food later develop a starvation acidosis and this added affliction
may even dominate the picture. It is in this type that the soda and sugar
solution produces the most brilliant results.
I may mention a case typical of the class. The patient had been treated
by the usual methods but had steadily grown worse until her condition had
become so critical that she was sent to the hospital to have the pregnancy
terminated. However, the administration of the soda and sugar solution
by the Murphy drip produced immediate improvement and the patient had
no more toxic symptoms, but passed on through an uneventful convales-
cence to a normal pregnancy and continued so to full term.
With regard to the anaesthesia in eclampsia, of course, this is one of the
most important points in the management of these cases. The ideal would
be to get along without a general anaesthetic using only local as suggested
by Dr. Roberson. But, as Dr. Lawrence has indicated, these patients gen-
erally come to you after having had several convulsions and are often coma-
GYNECOLOGY AND OBSTETRICS 149
tose, and, therefore, require very little anaesthetic. Usually the cases we see
have had morphine ; just a little ansesthetic to get them on the edge of nar-
cosis and you are able to proceed with the operation.
As I mentioned before, some of these cases have a predominating liver
involvement; in these one would avoid chloroform. In a case showing be-
ginning pulmonary cedema one would avoid ether. In a case showing pre-
dominating kidney involvement one would prefer to use neither one, yet in
the majority of these cases the amount required is so small that I feel that
the objection to their use is more theoretical than practical.
Dr. F. Webb Griffith^ closing discussion: Dr. Roberson asked one or
two questions.
One of them was — what are the indications for the termination of preg-
nancy in tuberculosis. Personally, I don't have to decide that, for in Ashe-
ville we have a whole host of lung men who can decide it for us. However,
in a general way there are two groups of cases, those who are far advanced
with tuberculosis and where it is obvious that tremendous damage will be
done if pregnancy continues to full term ; the other group where the lesion
in the lung is so slight that to allow pregnancy to proceed to full term the
patient is deprived of the excellent chance she would otherwise have in get-
ting over her tuberculosis. .1 recall a case where a curettement was done
and the condition of the mother immediately greatly improved. She soon
became pregnant again and her physician, a most competent specialist in
pulmonary diseases, felt that he could not give his sanction for a second
curettement. Patient went to full term, gave birth to a healthy child and
died shortly afterwards. That brings up a fine moral question — Is it better
to prolong the life of the mother for a few months or even a year or two
and sacrifice the child, or should a short time of the mother's life be sacri-
ficed in order that a child may have its chance to live out its normal life?
Frankly I do not know how to decide such questions. The very hardest
cases to decide are those early cases of pulmonary tuberculosis where the
patient has every hope of getting well if she is not pulled down by a pro-
longed pregnancy. So that by doing a curettement you give her the one
chance in her life to be well and probably in a few years she can have healthy
children. These are the cases where the lung men must decide and not the
surgeon. In the toxemia of pregnancy if you have in association with you
two level headed physicians I believe they can usually decide pretty well
when the patient is getting to the danger point.
I have enjoyed Dr. Roberson's paper very much and am glad to see that
we are getting more and more away from what has been described as "Gyne-
cological tinkering." Local application and tampons have a very valuable
place, but I know of nothing which is more overdone than such treatments.
You recall that the outer part of the cervix is lined by many layers of
epithelium and the blood vessels underneath give to these layers a bluish tint.
Now the inner lining of the cervix has only one layer of epithelium and the
blood vessels showing through appear red. So that when there is a bilateral
tear the physician frequently sees this red everted inner lining and calls it
ulceration. He will apply silver nitrate or some other caustic which will
cause a proliferation of epithelium and he then consideres the ulceration
cured. After a time these proliferated cells desquamate and the condition
150 NORTH CAROLINA MEDICAL SOCIETY
recurs. The patient is then given another course of treatment and the same
cycle will be kept up as long as the patient will stand for it. Just as Dr.
Roberson has pointed out either these patients need nothing at all done or
else they need radical treatment such as repair or amputation of the cervix.
As to cancer of the womb there are two types, the squamous-celled and
the adeno-carcinomata. I have never seen a case of the former except where
there has been some trauma to the cervix, such as instrumental dilation at
pregnancy. After doing a hysterectomy I think it is an excellent procedure
to cup out the mucous membrane of the cervix for in so doing you can get a
better closure and will prevent a subsequent leucorrhea. While this cupping
by removing the glandular element of the cervix would theoretically pre-
vent adeno-carcinomata it obviously could not prevent squamous-celled can-
cers.
The paper on csesarean section has been very interesting. In a great ma-
jority of cases the decision for or against Csesarean section is entirely the
question of the child. If you have a dead foetus or if pregnancy must be
terminated before the child is viable, Caesarean section is practically always
contra indicated. Very often vaginal Caesarean section should be done in
preference to the abdominal, but after all is said the method should be chosen
which gives the greatest safety to the child without correspondingly greater
danger to the mother.
EYE, EAR, NOSE AND THROAT
WHAT CONSTITUTES GOOD TONSIL SURGERY.
John W. MacConnell, M. D., Davidson, N. C.
What constitutes good tonsil surgery? This question is propounded in
no cynical mood, nor in criticism of any colleague's work, neither have I
any new or startling method of my own to put before the Society. My
idea in this discussion is to arrive at some basic facts in connection with ton-
sil surgery as it is generally done, and as we would like to do it, two condi-
tions which are not at all times similar. The proposition of tonsil surgery
in its simplest analysis is only that of removing two vestigial glands in the
right and left faucial regions, on account of their diseased condition.
The operation is not a new one — rather the reverse, for it is one of the
oldest operations in surgery. The early Greek and Roman surgeons divul-
sed the tonsils, tearing it out with a hook or with the finger nail, both of
which practices are still in use and some operators make a great deal of their
work of finger dissection and speak of it with some show of originality,
whereas both Hippocrates and Celsus advised the method, the former as
early as 460 B. C
Tonsil enucleation is difficult because of the location of the tonsil, which
is rather deep in the throat and surrounded by prominent structures and
the operation is complicated by the free bleeding and salivary secretions
accompanying any surgical procedure in these parts. To overcome the diffi-
culty of operating in a narrow space, at a fair depth, various instruments
have been designed, many of them freakish in appearance, some utterly
void of any mechanical attraction or convenience, but designed frequently
by one who was lacking in manual dexterity, and who had tried to over-
come his awkwardness with an instrument of many twists and turns. I
was interested in counting the number of instruments listed for tonsil sur-
gery in one of our recent catalogues. There were advertised in one cata-
logue alone 122 instruments for removing faucial tonsils, surely a travesty
on surgical skill.
Good tonsil surgery consists in removing the tonsil in its capsule entirely,
without injuring adjoining structures, particularly the faucial pillars and
the musculature of the pharyngeal region. This being the proposition, it
is wise to acquaint ourselves with the surrounding tissues to avoid injuring
any, and to remember the anatomy of the parts. The tonsil is embryonic
tissue, developed in three lobes, which sometimes remain, but generally
only two lobes can be made out in an adult tonsil. These are the two
lower lobes, the superior lobe being found only on deep inspection of the
supra-tonsilar fossa. The plica-triangularis is an operculum of tissue cover-
ing the upper part of the tonsil in its embryonic development, then splitting
into an anterior fold the plica-pretonsillaris which runs down to the base
of the tongue, and a posterior fold — the plicainfra-tonsillaris, the two folds
with the base of the tongue forming the fossa-triangularis. This is the region
in which we work and all these tissues are to be respected, and should re-
main uninjured in a tonsil enucleation.
The tonsil rests in this area surrounded by a distinct fibrous capsule. Its
size and shape vary, but the surrounding structures are constant, though
152 NORTH CAROLINA MEDICAL SOCIETY
they may be distorted by adhesions and frequent inflammations. The blood
supply is chiefly from the tonsillar branch of the facial artery — which
branch breaks up into smaller vessels at it enters the tonsil, and these fol-
low the trabeculae of the capsule as it is infolded in the lymphoid tissue.
In tonsils chronically inflamed, there is often developed a plexus of veins
much larger than the normal, and which give great trouble in post-opera-
tive oozing without there being a specific bleeding point to ligate. The
facial artery may take an upward swing where it passes beneath the tonsil
and it is a possibility that it may be injured by a sweep of the knife in the
deeper tissues — the writer has never seen this accident. The lower part
of the tonsil may be supplied from a branch of the lingual and the posterior
superior part by the palatine branch of the ascending pharyngeal. I have
seen this latter condition a number of times as I am sure all of you have,
and it shows as a rapid spurter in the upper segment of the tonsillar fossa.
Good tonsil surgery — should be as surgery in any other part of the body —
that is it should rest upon proper respect for tissue, a proper acquaintance
with the parts, every vestige of tonsil should be removed, no other tissue
should be removed, and a proper hemostasis should be maintained both dur-
ing and after the operation. Tonsillotomy, slitting of crypts, and the gal-
vano-cautery have no place in good tonsil surgery. If the case needs remov-
al of tonsils — they should be removed — just as an offending gland or tumor
would be removed in any other part of the body. To do this there is only
one true surgical operation and that is the enucleation with knife or scissors
of the entire tonsil and its capsule, leaving the pillars undamaged, ligating
any bleeding points before finishing with the patient. Whether a snare is
used at the latter part of the operation is a matter of no particular import-
ance, though most of us do so, for the lower border of the tonsil is not well
defined and runs down sometimes to a point as thin as a shaving, and the
snare will follow the line of demarkation down very successfully. The'
operation mentioned will remove all tonsils not a group of selected cases
and the writer considers it the only true surgery of the tonsil. Finger dis-
sections and the Sluder operation will be a success in a certain percentage of
cases, but the writer does not think that it is wise to select several different
methods of tonsil enucleation when one operation can be perfected which
will successfully remove any and every tonsil. The operation outlined is
equally good whether the patient is under local or general anaesthesia, and
whether it is a child or an adult. The writer uses novocaine for all cases
of local anaesthesia and ether for general anaesthetic. Results are as good
under local as under general anaesthesia, though naturally we can work
more rapidly and easily under the local. Some of my colleagues inject a
small amount of adrenalin-novocaine solution into the anterior pillar even
when ether is used and, while not strictly a good surgical procedure it has
advantages for the prevention of capillary oozing during the operation,
shortens the time, and if the operator is experienced, as my colleagues are,
the same respect for tissue will be maintained whether there is oozing or
not. In the hands of some, the procedure is not wise, for the operator is
more daring when the tissues do not bleed and frequently goes deeper than
he thinks and has secondary hemorrhage when the effect of the adrenalin
wears off.
I am advocating no particular type of knife or scissors. Just a good sharp
EYE, EAR, NOSE AND THROAT 153
instrument introduced under the anterior pillar of the tonsil where it is not
adherent, then sweeping the knife around the tonsil going well up under
the frenum of the plica, for if the upper lobe is well separated the operation
is half done. Traction towards the median line enables one to strip the ton-
sil down to its inferior pole which may be divided with the knife or snare.
Retraction of the anterior pillar forward allows inspection, then any bleed-
ing points are caught and ligated, or twisted until the fossa is dry. Especi-
•4lly should the fossa be dry before the patient leaves the table or operating
chair. At no other time will the patient be under such good control, and
if they are taken in the operating room later to have something dene to
stop any hemorrhage, however slight, they have lost the necessary confi-
dence, and are fearful that some accident might have occurred.
Hemorrhage is the bugbear of most tonsil operators and is not altogether
a fanciful danger for severe hemorrhage does sometimes take place, and any
man who does a sufficient number of cases will have some which will bleed.
My own routine is to give the calcium salts the day before the operation in
large doses, and I am confident I have had less capillary oozing or venous
hemorrhage since that time. In my experience I have had four hemorrhages
which were severe, though in a retrospective view they do not appear as
alarming to me as they did at the time. One was an operation to remove
stumps from a previous tonsilotomy of another surgeon some years before.
I was operating in a strange hospital without any of my own instruments
and did a scalpel dissection in which I may have wounded the pillars and
the bleeding kept up until the blood pressure was lowered enough to make
the flow stop. The second was on a case of known hemophilia, when I was
more daring and less experienced than now, and the bleeding kept up a
couple of days, then ceased and the ultimate results were excellent. The
third was a middle aged man with a case of pyorrhea — which cases have
always seemed to bleed more than others. This oozing kept up for twenty-
four hours and the patient was severely shocked before it corrected itselt
The fourth was in a choreic young girl, at the age of puberty — was second-
ary in character — lasted twelve hours — was due to a small piece of tonsil
left under the plica in the upper fossa and as the patient was removed to
her home before the bleeding commenced I found myself handicapped by
not having proper assistance. In a hospital her case should have been
easily controlled.
I mention these cases to show that I have not yet reached my ideal in ton-
sil surgery. My work in examining college students for the last thirteen
years and two and a half years of army service in examining the throats of
thousands of men has given me a fair index as to now tonsil surgery is gen-
erally done over the United States, for I never look into a throat which has
had an operation that I do not ask, who operated and how long since. I
beg you to notice that I make no comment on the character of the work to
the patient and I think we should always be careful in our remarks to the
laity upon the result of any operation for such misunderstanding can be
avoided thereby. The errors noticed might be summed up as follows:
First, failure to remove the entire tonsil. There is no question that if
the tonsil is entirely enucleated it does not return but if part is left, it may
continue to hypertrophy and the former condition be unremedied.
l54 NORTH CAROLINA MEDICAL SOCIETY
Second, removal of a part of the constrictor muscle of the pharynx. This
muscle is sometimes rather adherent to the capsule and if many of the mus-
cle fibres are removed a hardened scar results and the patient will complain
of a feeling of tightness in the throat which is uncomfortable.
Third, injury to the pillars, by the knife or snare, and in occasional cases,
part of the velum palati has been removed and the uvula as well leaving a
distorted pharynx. _
Fourth, some general surgeons who remove tonsils are frightened by the
blood, which is more than occurs in many abdominal operations and they
seek to prevent it by suturing the pillars which is always bad practice, for
if any vestige of tonsil remains it will be deeply embedded and give trouble
certainly, and the sewing of the pillars together causes undue tightness ot
the pharynx. If at any time it becomes necessary to suture the pillars to
prevent hemorrhage the sutures should be removed early and an elevator
passed between them, separating them permanently.
Conclusions: There is a great improvement in the tonsil surgery of the
past few years, but there is the tendency to experiment upon different types
of instruments and operations rather than adopting a simple surgical techni-
que and perfecting that operation which will suit all cases.
2. Though some continental surgeons hold that tonsillotomy is an opera-
tion of choice, our experience in America is that the entire tonsil should be
removed in its capsule and that if the operation is thoroughly done no injur-
ious consequences ever follow, and that such consequences are due to imper-
fect surgery and not to the tonsil operation per se.
Dr. J. B. Greene^ Asheville, N. C. : I wish to express my apprecia-
tion of Dr. McConnell's excellent paper.
It pleased me, particularly, that the dissection of the tonsil is advised
rather than the Sluder method. I am of the opinion that the latter method
is losing somewhat its former popularity.
The doctor speaks of venous hemorrhage from the tonsillar fossa after
operation. It has seemed to me that such bleeding is practically always ar-
terial, though at times the artery is difficult to locate.
In reference to the administration of Calcium Salts prior to operations, I
would like to state that I have little faith in such medication since the use
of this drug some years ago in a case in which I particularly desired immuni-
ty from troublesome bleeding, was followed by most annoying hemorrhage.
Since that time I have not used Calcium lactate, and have had little post-
operative bleeding.
In reference to the use of adrenalin chloride in our local anaesthesia solu-
tions, I am in the habit of using eight drops of the one to one thousand solu-
tion for the removal of both tonsils. I realize that some operators refrain
from the use of adrenalin chloride for the fear of early secondary bleeding.
This has been a rare symptom in my experience.
Dr. J. P. Matheson, Charlotte, N. C. : "I think the Society should
express their appreciation to Dr. McConnell for such a timely paper, and
such a thorough discussion of the subject. I would like to mention one or
two things that I consider important in tonsil surgery.
To make tonsil surgery easy, as well as effective and to do the least
EYE^ EAR, NOSE AND THROAT 155
amount of traumatism to the patient's throat, it is necessary to have a first
class aniESthetist, and I prefer one who is constantly giving ether for tonsil
work, and who at the same time can act as your first assistant. This makes
the operation much quicker, much safer, and often with very much less
traumatism to the patient's throat. Second, in local work, I prefer to do
these in my office, and keep them there for three hours afterwards, and then
send them to the hospital. In this way you save considerable time, your pa-
tient has very much less excitement, and in case of hemorrhage or other
complication, you have easy access to your patient, and can give your imme-
diate personal attention. If at the end of three hours there is no sign of
tonsil bleeding, you can feel very comfortable. Usually hemorrhages of the
tonsil after local begin to show very soon after the operation, or at the end
of about two hours, and in having your patient present on a comfortable
couch saves a considerable amount of time, annoyance, and excitement
should it become necessary to stop a hemorrhage.
CONSERVATISM IN TREATING FOCI OF INFECTION.
By J. G. Murphy, M. D. Wilmington.
When I promised our late co-worker and friend, Dr. E. Reid Russell, at
the close of the Pinehurst Meeting to write a paper to present at this time,
I had in mind writing on "Astigmatic Corrections," and results we get
from same, but I have been so impressed in my practice during the year
with the importance of the subject I am bringing to you that I thought
this would be of more practical value and especially so if it brings out a dis-
cussion. That would be worth more to us than the paper itself. Of course
any doctor is obsolete and behind the times who does not believe in foci of
infection, and not only believes in them but practices hunting for them in
his daily work. While I am writing this beginning of my paper, there is
under my care a patient who came in recently with a disturbance of vision,
and on examination I found him to have a lens opacity. He was too young
for a senile cataract so I began to look for a cause for a visual disturbance
of this type and I found the antrum under the affected eye to be full of pus-
This was drained and in ten days he was relieved of symptoms that were
present before, and his vision is improving.
Now, do not think that I am coming to you to write on the hackneyed
subject of simply clearing up foci of infection for that is an idiom in surgi-
cal practice today, but what I do wish to emphasize is this, that the focus
of infection may be far remote from the organ giving the symptoms, and
about which we have been consulted and in our zeal for the patient, and by
our lack of knowledge of the proper mode of treatment of the focus as locat-
ed by us in our examination we are apt to suggest a line of treatment, which
will probably be carried out by the specialist to whom we send him, because
of the fact that we suggest that such should be done. Would it not be bet-
ter if we would send the patient to the specialist to whom his focus belongs,
and ask that they decide on the best means of relieving a condition which we
have found to exist. Possibly by the process of elimination we have located
the focus producing existing symptoms in our field of specialty. The one to
whom we send the patient is better fitted to pass on these conditions than the
Ophthalmologist or Oto-laryngologist. I can make myself clearer in cor-
recting these errors we have made by sighting some cases which have un-
156 NORTH CAROLINA MEDICAL SOCIETY
doubtedly come into the practice of every specialist here present, for instance,
we have myriads of symptoms and on examination find that the focus caus-
ing these symptoms is in the teeth, and we, using a degree of positive authori-
ty, tell the patient they must have their teeth extracted, and our advice is
likewise carried out, and our patient becomes a victim of our ignorance. We
have assumed to pass on a subject which should be decided by the dentist.
You can see our mistake because the doctor to whom he goes thinks we have
some reason for our positive advice, when in reality we are only asking to
remove the focus of infection. The specialist to whom he is sent might be
a dentist who prefers, and according to his practice does more easily relieve
by treatment, than by the more drastic means of extraction.
There is no harm in taking out the appendix as a possible source of in-
fection, nor is there any harm caused by removing tonsils. These organs
have no functions, but do not advise removing the teeth unless you are com-
petent to make such a diagnosis.
THE RELATION OF PUBLIC HEALTH WORK TO THE BUSI-
NESS INTEREST OF THE EYE, EAR, NOSE AND THROAT
SPECIALISTS OF NORTH CAROLINA.
G. M. Cooper, M. D., Director, Medical Inspection of Schools^
State Board of Health, Raleigh
Mr. Chairman and Gentlemen :
When I was awarded the courtesy by your Chairman, Dr. Banner, of
having a part in this program, after several days consideration of the matter
I decided to accept the generous invitation extended to me, and chose
for consideration the above subject. It is my purpose to discuss this question
briefly, frankly, and impersonally. In order to keep our perspective clear
and because he has expressed so definitely and concisely my own conception
of the work of the physician individually and as a class, I am quoting the
following paragraph from a recent presidential address before the American
Neurological Association by Dr. James H. McBride, of California:
"It is an important truth that nothing stands alone in this world, not
even a medical association. We go up or down together. We are here
today not solely because we are physicians, but also for the reason that
society created us as a profession because it needed us, and we are therefore
always serving its purpose. Our most private work is really a social and
public work, so that in all we do we are going on the errands of society.
Each one of us is an essential part of this moving human order that keeps
society together and holds humanity to its sober task.
"In this period of industrial and social reconstruction, when all interests
are becoming intertwined, when human interspaces grow smaller, and new
relations create problems that change our views of life and society, it is
necessary that the medical profession also make certain readjustments and
that it annex human interests to its older activities, if its members are to
maintain its fine traditions and keep step with social progress."
Something like ten years ago, when the real progressive sections woke up
to the importance of enforcing compulsory vaccination against smallpox as
the only means of combatting that disease, and when the wide-awake school
EYE, EAR, NOSE AND THROAT 157
boards of these same sections began to enforce the requirement of vaccina-
tion before pupils should be admitted to the public schools, considerable ap-
prehension spread throughout the length and breadth of the State on the
part of a great number of physicians, many of whom openly expressed the
fear that the activities of the health department in the control of smallpox
was going to make serious inroads into the income of the private physicians,
and that by paying for this vaccination service by the day and to a single
health officer in each county or city, instead of farming it out on the basis
of private fees, strenuous opposition developed as the perusal of the litera-
ture of that day will afiord abundant proof. This attitude is looked upon
today as ridiculous and the private physicians still have work to do.
About five years ago, when the State Board of Health began its first
systematic effort at the control of typhoid fever, one of the methods used,
especially for its educational value, was the ofifer of voluntary free vaccina-
tion against this disease. Here again we were met by the same cry that the
State Board of Health is encroaching in the field of private practice, and
that the physician's income is placed in jeopardy. The fear and apprehen-
sion was so wide-spread here that it became necessary for the Secretary of
the State Board of Health to discuss this matter formally at the meeting of
the State Medical Society as late as April, 1917. Today that attitude on
the part of these physicians appears just as ridiculous or even more so than
the fury against public vaccination against smallpox. The physicians are
still doing business and making more money than they ever have in their
lives.
There are today in North Carolina 836,000 school children enrolled in
the school census of the State. From accurate facts that cannot possibly be
disputed there are not less than 125,000 of those children needing operations
for removal of diseased tonsils and adenoids so badly that their parents,
their teachers and their neighbors will readily assert this fact. Many thou-
sands more of them have defective vision, latent and incipient tuberculosis,
defective hearing and other easily preventable defects, to say nothing of the
75% of this great total who have dental defects. Thus you see today, right
this minute, in North Carolina there are 125,000 children that need this
operation. They need it badly. The number is being each day augmented
by the new recruits of children coming six years of age entering school.
There are at the other end of the line passing out of school on into adult life
others who are carrying their handicaps, as I have done, all their lives for
the lack of this operation. Thus you see if the specialists in North Carolina
who have license to practice medicine and have hung out as specialists, both
part-time, full-time, or what not, were to begin operating on these children,
supposing that they were presented for the service, each man of you would
have to operate on 1475 children before the end of the year to clear up what
is enrolled in the schools today. This estimate is lower by at least 5% than
has ever been published by any responsible agency in the United States, a
recent writer in the Saturday Evening Post giving a 25% higher estimate
for the country at large than this.
Now, what are the real facts concerning these operations? It is this:
Less than 1 % of these children under the system that has been in vogue in
North Carolina up to and including the present, on the part of the special-
158 NORTH CAROLINA MEDICAL SOCIETY
ists and the public generally, will ever even consult a specialist. Less than
10% of them will ever even consult a general practitioner. Why? Be-
cause they have never been convinced of the necessity for such remedial
treatment and because of the morbid fear of the word operation and all that
it implies. This applies to the people who have the money as well as in-
digents.
The only concern the State Board of Health has in this matter is to con-
vince the people of the necessity for these operations so that every effort pos-
sible may be made in order that they have it done for the benefit of the next
generation of men and women of North Carolina. The work that the State
Board of Health has been doing is to make a mighty effort to arouse wide-
spread interest as to the necessity for the operation. We have found every-
where that the first thing that had to be combatted was that it is not a
scheme to.make money for doctors.
The one reason that medical inspection of schools as practiced in a routine
manner in the United States has been productive of so little real good has
been that when a child is examined in school by a medical inspector or nurse
and a note sent to the parent advising that the child is not physically normal
and urging that a physician be consulted, ninety-nine out of every hundred
of them throw the card in the fire with the comment that "this is just afford-
ing jobs for doctors who cannot make a living, and for old maid nurses;
and then it is being done chiefly in the interest of doctors who want to get
the children to treat." Consequently, when we take it absolutely out of
the field of commercialism and center our whole efforts on the operation,
only beneficient results may be expected to follow. To do this without
classification of childrn according to social or financial standing, race, color
or creed, we are finding a much better comprehension of what the opera-
tion means. And what it means, when this sentiment is crystalized and
universally accepted by all the people in North Carolina, to the business in-
terests of every specialist practically a one-eyed man or a fool could readily
see.
Again the best time to do these operations and the time that we urge upon
everybody is in the pre-school age immediately preceding the starting of the
child to school. It is a common practice now to hold children out of school,
as a rule, until the beginning of their seventh year, and very wisely so I
think. Therefore, we urge upon the people the necessity of having these
operations done during this period — from five to seven years of age, — when
possible. That naturally places this in the hands of their private practi-
tioners and private specialists, because school physicians have nothing to do
with the children until they are enrolled in school. You can see there the
enormous business benefits to the specialists wherever this advice is accepted
and put into practice.
In conclusion, I may state that the prime reason for the existence of a de-
partment of medical inspection of schools of the State Board of Health is
(1) to find defective children and get them treated; (2) to convince the
parents and guardians and teachers of the children from Cherokee to Curri-
tuck of the necessity for the correction of remedial physical defects as early
as possible; (3) it is our aim and intention to work in the utmost harmony
with the medical profession, especially the specialists of North Carolina,
EYE^ EAR^ NOSE AND THROAT 159
and with the teaching profession and school authorities in the attainment of
this idea. Your assistance is needed and will be appreciated now and in
the future as in the past.
Wm. S. Jordan :
Mr. Chairman :
"I had not intended having anything to say in regard to this matter, but
I must object to the suggestion that the chief objection to doing this work
in this way is because it deprives the doctors of fees that ought to be paid.
There are plenty of doctors who would be willing to do any number of de-
serving cases for no fee at all and too without being known in the transac-
tion for that matter. I feel that it is unbecoming to seek the cooperation
of the profession by holding out the benefits of the advertising received. If
it is a good thing to do the doctors ought to be glad to render the service
and keep their personalities in the background. If there were no other ob-
jections to the method this one is enough to place it outside the proprieties
of practice. As a matter of curiosity it would be interesting to know how
many of those engaged in this work would do it so enthusiastically or at all
if they felt they were to be deprived of the advertising they receive thereby."
Question : — Dr. Louis N. West and Dr. H. M. Bonner.
"How are operators selected to do clinical work for the North Carolina
State Board of Health ?"
Answer: — Dr. G. M. Cooper.
"I can best answer that question by giving a recent illustration in the
matter of selecting operators for a clinic to be held in Duplin County within
a few days. The nurse was instructed there while making her survey
throughout the county to ascertain from the parent of each child requesting
3n operation, and also from the various physicians practicing in the county,
who their choice of an operator would be if it was a private matter. The
result was that the choice was about equally divided in different portions of
the county between one Wilmington specialist, one Goldsboro specialist,
and one Raleigh specialist. Therefore, I have arranged a three-day clinic,
conducted one day at a time by each of these three specialists. The depart-
ment has made every effort to be absolutely fair to all reputable specialists
practicing in different sections of the State. We have tried to be just as
fair as if the selections were made in private practice."
THE COMPARATIVE VALUE OF ROENTGENOGRAPHY
AND TRANSILLUMINATION IN DIAGNOSIS OF DISEASES
OF THE FRONTAL AND MAXILLARY SINUSES, WITH
DESCRIPTION OF AUTHOR'S METHOD OF
ORBITO-PALATOBUCCAL ROUTE OF TRANS-
ILLUMINATING THE MAXILLARY SINUS.
H. H. Briggs
Roentgenography and transillumination offer valuable objective evidence
of the condition of the superficial nasal accessory sinuses. Which of the
two is more valuable is debatable, depending upon the anatomical relation-
ship, the modus operandi, and upon how much the observer has studied the
various methods of each while comparing his diagnosis with his surgical
160 NORTH CAROLINA MEDICAL SOCIETY
findings. The one method supplements, frequently corroborates, and oc-
casionally refutes the findings of the other. If they did more they would
together form the sine qua non of sinus diagnosis, and their findings would
be pathognomonic. If taken jointly, and in connection with other symptoms
and signs, they often prove to be determining factors in establishing a diag-
nosis, and frequently suggest the proper therapeutic procedure. All agree
that the roentgenogram better outlines the sinus, and offers definite limits
to guide the operator. It alone furnishes positive evidence of absence of a
frontal sinus, the shadow of which by transillumination might indicate an
infected sinus. On the other hand, the rays making the plate must pass
through the head, the greater part of which is foreign to the parts we wish
x-rayed. Consequently there may be in the plate misleading shadows caused
by many parts within the cranium posterior to the sinuses. On the other
hand the translucency of a sinus is little interfered with by extraneous parts
except by slight variations of thickness in the bony walls and overlying soft
tissues. Transillumination requires less skill, is quickly and inexpensively
done by the clinician himself, while the roentgenogram, correctly made, is
the product of a rather highly specialized, and, therefore, expensive techni-
cian, requiring careful interpretation by either the technician, or preferably
the clinician. It is just as essential for every clinician to be able to inter-
pret the roentgenogram — altho he may not have made it — as it is for him
to perceive the translucency of the sinus by the electric light. Every sinus
plate reveals details to the interpreter which no one can fully describe to
him, and to operate from another's findings is like striking where someone
points.
Roentgenography: It is not intended to describe here the technique of
making sinus plates other than to discuss the two usual positions of exposure,
namely, the nose-chin, and nose-forehead positions of the plate, and to de-
scribe the special advantage of each in exposing the frontal and maxillary
sinuses. In either position the axis of the tube should be parallel with the
plate, and the principal rays should pass through the special part to be radio-
graphed at right angles to the plate. Authorities agree that a soft tube with
intensifying screen and a moderate amount of milliamperage are best adapted
for the deep penetration and detail demanded in sinus roentgenography.
(Waters and Weldron (1) American Journal of Roentgenology, February
1915, VII, Number 4, page 633.) For the sake of correct detail the part
to be exposed should be placed as close to the plate as possible. At the same
time consideration must be given to the density of the tissues through which
the rays must pass before entering the sinus which is to be x-rayed, and to
fulfill these conditions the position approximating the nose-chin position of
the plate is most admirably adapted for the maxillary sinus. The base of
the skull offers two prominences of bone of considerable resistance ; viz : the
lesser wings of the sphenoid, and to a much greater degree the petrous por-
tions of the temporals. It is, therefore, desirable to select a position that
will allow the projection of these parts to fall on the plate outside the pro-
jection of the sinus which is to be x-rayed.
In the nose-chin position the projection of the lesser wings of the sphe-
noid bisects the orbits horizontally, and are seen as narrow curved lines
passing outward and upward through the orbit, and the petrous portions
are superimposed on the upper incisors, and therefore, just below the shadow
EYE^ EAR, XOSE AXD THROAT 161
of the antrum. The exact position of the plate with reference to the nose
and chin depends upon the type of face. In the average physiognomy the
tip of the nose should be about one centimeter from the plate; one with
prominent nose and receding chin should rest with nose on plate, or perhaps
pressed deeply against the latter, while the opposite type of dish-face may
require the nose lifted one or two centimeters from the plate. In the nose-
chin position rays passing through the maxillary sinus first pass through the
middle fossa of the skull above the petrous processes of the temporal, and
below the lesser wings of the sphenoid. Projected within the shadow of
the maxillary sinus, and near the nasal wall may frequently be seen the
foramina, altording exit for the optic and the three divisions of the fifth
nerves, especially the foramina rotunda, and ovalia lying more latterly, and
being the more easily outlined in the normal sinus.
The nose-forehead position is ill suited for the maxillary sinus, as in it
the petrous processes are projected across the antrum often with such density
of shadow as to completely obscure the details, mislead the interpreter, and
simulate a pathological condition of the sinuses. This position is perhaps
the befier routine method fur the frunf.l sinus, especially if an exact out-
line of the upper limits of the sinus is desired, and provided that the prin-
cipal rays are directed from a position sufficiently forward to bring the lesser
wings of the sphenoid below the supercilliary ridge. It is not so well adapted
for the outline of the orbital extensions of the frontals, and the anterior
ethmoid cells as is the nose-chin position, because of the shadows of the lesser
wings of the sphenoid, and the base of the anterior fossa.
Transillumination : The value of transillumination depends on the inter-
ference which the pathological contents and thickened mucosa of a diseased
sinus offers to transmitted light. A perceptible interference to light is
shown by uncontaminated mucus, and more by normal mucous membrane ;
and when the latter becomes swollen and hyperemic, and the sinus filled
with mucopus and detritus, especially in chronic infection, a high degree of
illumination becomes necessary for translucency. Since we are concerned
with the light-interference caused by the diseased processes in the sinus
cavity alone, it is highly iinportant that the light, before entering and after
passing out of, the cavity, should encounter as little interference from ex-
traneous bone and soft tissue as possible, and to this end the essayist wishes
to describe a method of transilluminating the maxillary sinus which he has
used with gratifying results for eleven years, viz: "An orbito-palatobuccal
route of transillumination." The advantages claimed over the palato-facial,
or Heryng method are :
(1) The light passes through less extraneous (to the sinus) tissue.
(2) It passes through opposite instead of adjacent sides of the sinus, and,
therefore, penetrates deeper into the cavity.
(3) It takes less time.
(4) It is more cleanly.
Author's Method : The patient is placed on a high stool in a dark room,
requested to tilt the head backward, and open the mouth. The cheek is
retracted with a tongue depressor so as to bring into view not only the hard
palate, but that part of the floor of the antrum in the buccal cavitj- outside
and above the molars.
162 NORTH CAROLINA MEDICAL SOCIETY
The light is placed against the lower lid above the infraorbital notch,
pushed inward, and pointed downward until the infraorbital is well passed,
when an area of pink will be seen on that part of the roof of the mouth and
buccal wall on either side of the alveolar process corresponding to the floor
of the antrum.
That the extraneous tissue in this orbito-palatobuccal method are less
extensive, and offer less resistance to the light than in the Heryng method
is evident after comparing the thickness of the antral walls in the valuable
data given by Davis in his classic monograph (2) : "Nassal Accessory Sin-
uses." (Ann. of Rhi., Otol., & Lar., Sept., 1918), as follows: "The orbital
wall is a thin plate of bone from 0.5 to 1.5 mm., and the facial from 2 to 5
mm.," or 3 to 4 times as thick as the orbital wall. Thus the light passes
through only one-third as much bone, and far less soft tissue in entering the
antrum through the orbit in the author's method, as it does in its exit from
the antrum through the facial wall in the Heryng method. In each case
the light passes through the roof of the mouth. In the new method there
is the added advantage of being able to observe the translucency outside of
and above the molars, as well as in the roof of the mouth ; in fact the entire
floor of the sinus where pathological conditions are most usually found is
outlined and transilluminated.
Route of Transmitted Light Through Antrum : The popular fallacy in
the palato-facial method of Heryng is the presumption that the light passes
directly through the antrum. As a matter of fact, the greater part passes
first through the floor of the nostril into the nasal cavity, then through the
lateral nasal wall into the antrum and through the upper inner and anterior
corner of the antrum, escaping entirely any localized pathological condition
of the sinus lying over the roots of the teeth and outer antral wall, which
is the most frequent site of pathology, especially when the infection is of
dental origin. Apropos this is the following quotation from Logan Turner,
"Accessory Nasal Sinuses, 1910": "With the exception of a very small por-
tion of the outer edge of the palatal plate of the superior maxilla close to
the alveolar margin the roof of the mouth forms the floor of the nose, and
has no part in the formation of the floor of the antrum, this wall being
formed by the alveolar process which bears the teeth. The typical floor is
over the molars, and the posterior portion of the second premolar, and in all
stages of development is in close relation to the teeth, there being always
a bony covering over their roots." A further quotation from Turner will
help to remind one how far, laterally, the inferior fosas of the nose extend:
"In an antrum of average dimensions the outer border of this latter
(canine) ridge indicates externally the line of union between the facial and
nasal walls of the cavity." Quoting further: "When the lamp is placed
in the mouth some of the luminous rays enter the maxillary sinus directly,
while the remainder pass into the nasal cavities, and thus reach the antra
through their nasal walls." It is very evident, therefore, that when (as
frequently happens) a septal spur or an enlarged inferior turbinate or some
other abnormal condition fills the inferior fossa, transillumination by the
old method is very materially interfered with, and its interpretation ren-
dered faulty.
PEDIATRICS
THE IMPORTANCE OF LUMBAR PUNCTURE IN INTRA-
CRANIAL HEMORRHAGE OF THE NEW-BORN.
REPORT OF A CASE WITH RECOVERY.
Dr. J. BUREN SlDBURY^ WiLMINGTON, N. C.
Intra-cranial hemorrhage of the New-Born is not an uncommon occur-
rence. On the contrary, it is much more common than any of us know, due
to difficulties in its recognition in some cases. At times it is not only very
difficult of recognition but even impossible to make an absolutely certain
diagnosis, antemortem. It may occur in any type of delivery. The most
usual history is that following a prolonged labor, with or without instru-
ments. It may occur, however, in the so called normal labors and not in-
frequently does it happen to the premature baby. Two such cases have oc-
curred in my practice in the last three years.
This condition was first properly interpreted by Sarah McNutt ( 1 ) in
1885. It was brought more into prominence some twenty-five or thirty
years later by Little. That the majority of these cases are born dead or die
soon after birth we do not wonder at. However, there are a certain num-
ber who do survive. Of the total mortality under one year of age 30% is
due to Congenital disease of which syphilis ranks first and this condition
not far behind.
Etiology: The cause of this condition may be divided into two general
heads. First, Spontaneous or hemorrhage due to a general condition as
Hemorrhagic Neonatorum.
Second, and most common cause is Traumatic. Under this bead the most
common causes are: (1) prolonged, tedious or hard labor, with or without
instruments; (2) precipitate labor with injury to the child's head; (3) in-
judicious use of Pituitary Extract; (4) breech extraction of the after-com-
ing head; (5) premature babies have very fragile blood vessels which are
not strong enough to undergo the amount of pressure necessary even in a
normal delivery, hence their predisposition to this condition.
It is unquestionably true that a large majority of the infantile cerebral
paralyses occur either in first born children or in those who have been born
after prolonged, dry, hard labors. That prolonged, hard labor is a most
important factor in the production of this condition, I think, goes without
question. The early intelligent application of the forceps will reduce the
length of labor, thereby reduce the length of time the head has to undergo
this pressure. Other things being equal and the mother's condition good, is
it not wiser to cut down the period of labor and not wait until the mother
is exhausted and the foetal heart is imperceptible before offering help?
Pathology: If we think for a moment how delicate the brain tissue and
the capillaries of the new-born must be we wonder why more cases do not
occur. The bleeding may occur any place in the cranial cavity, in the vessels
of the duramater, in the piamater, in the arachnoid membranes, in the brain
tissue or ventricles. It may be small and punctate or it may be diffuse and
cover one or more hemispheres, forming a clot of varying size and thickenss
It may even occupy a third or fourth of the cranial cavity, in which event it
164 NORTH CAROLINA MEDICAL SOCIETY
will cause compression of the brain substance and back pressure of the venous
circulation, and, in turn, may rupture other capillaries. If the clot covers
any other area than the motor area we may get no symptoms at the begin-
ning, but later a condition of imbecility or epilepsy may develop with no
other signs. The location more than the amount is likely to give rise to
symptoms. We may have quite a large hemorrhage in the so called silent
area without giving symptoms at the time of bleeding. A small hemorrhage
in the motor area is more apt to give rise to symptoms. Hemorrhage at
the base of the brain may give rise to symptoms not unlike meningitis, due
to basilar irritation.
How long the blood stays in a fluid state or how long it takes the blood
to clot is not definitely known but we do know that it does not clot so
readily as it does on the outside of the body. When a lumbar puncture is
done on some of these cases as much as two ounces of fluid blood which
clots readily in the test-tube has been obtained. When you get that much
pure blood on lumbar puncture I do not think that it can with fairness be
attributed to a contaminated puncture. This happened in the one case
which I am reporting with recovery. In this case I obtained two ounces of
pure blood on lumbar puncture one hour after the first convulsion and five
days after delivery.
Mouno (3) reports a series of forty autopsies on infants dying within a
few days of birth, in which he found ten cases of rupture of the tentorium
and five of the falx cerebri. In all of these cases death was due to hemorrh-
age following the rupture, though the diagnosis was made first at the autop-
sy table. This emphasizes the frequency of the condition as well the in-
frequency of its recognition.
Green (4) reports two cases diagnosed before autopsy, one died on the
third day the other on the seventh, the latter showing a negative spinal
fluid. Both of these cases showed much fluid blood with small clots on the
surface of the hemispheres. Each of these cases gave a history of nursing
well and appearing normal for two and three days respectively at the end of
which time "they refused to nurse, had a feeble cry, developed a peculiar
pallor and facial edema." Neither of these cases had any of the typical
signs of compression.
Thrombosis is not an infrequent finding and in some cases would seem
to be the only explanation of the symptoms shown.
Symptoms: To have a new born baby nurse all right for two or three
days and then refuse to nurse, become pale and listless, with intermittent
periods or crying spells followed by stupor and perhaps convulsions or
twitchings of one or more muscle groups should make you think of a hem-
orrhage and especially so if the mother had a hard or instrumental delivery.
Convulsions following an instrumental delivery should make us suspect this
condition always. The following are the signs to bear in mind : Convul-
sions or twitchings of one or more extremities, bulging fontanel (not a con-
stant sign), nystagmus, strabismus which is more or less constant, increased
reflexes which may be more marked on one side, stiff neck and a Kernig's
sign may be present if the irritation is confined more to the base of the brain.
The pulse is strong, full and at times slow. The respirations are irregular,
they may be superficial and rapid or they may be slow and deep or may even
similate Cheynes-Stokes.
PEDIATRICS 165
While any or all of these signs may be present in any one case, there are
other cases which show none of these signs as was shown by the two autopsy
cases reported by Green (4). I wish to emphasize that there is no harder
diagnosis in medicine to make, with certainty, than some of these cases
which show none of the typical signs. Any obscure illness of the new-born
which can not be satisfactorially explained any other way should make us
think of hemorrhage or thrombosis, especially if there was a difficult labor.
The extreme type is seen in the Spastic Diplegias.
It must be born in mind that all symptoms may be entirely absent at
birth, and so far as the mother knows, the baby has been perfectly well un-
til about eight or ten months of age the mother brings the baby to the office
because she does not think the baby has been developing as a baby of his age
should. He does not sit up, does not grasp objects or show the proper in-
terest in his surrroundings. On physical examination, nothing definite is
usually found and the doctor tells the mother to go home and stop worrying
about the child for he will be all right or he will "out grow it." A more
careful examination will probably show that this child has an increased
spinal pressure of 10 to 20 mm mercury, not infrequently signs in the eyes
denoting intracranial pressure as papalitis or distended and engorged veins.
There is another or older type which may come to the doctor about the
age of puberty, either a few years older or few years younger, because they
have "peculiar spells." He may have epileptic seizures with or without
the loss of consciousness or he is unmanageable, incorrigable. These are some
of the latest signs of hemorrhage of the brain in the new-born. Whether
we have symptoms in early infancy depends upon first, the location, whether
it is in the motor or the silent area; second, the size of the hemorrhage. I
think every one will agree that there must be cases of birth hemorrjiage
which do not give any symptoms and which get entirely w^ell. Dr. Free-
man (5) refers to a case which had all of the signs of hemorrhage and com-
pression for which he advised an operation. The parents refused operation
and nothing was done and the child made a complete recovery. No Lumbar
puncture was done. This was a fortunate outcome, which, in my mind,
represents a very small percent of these cases. The risk of following this
as a routine is apparent.
Diagnosis: In every case of suspected intracranial hemorrhage a Lumbar
Puncture should be done. It will help in three ways. Letting off the
spinal fluid will relieve the intracranial pressure and stop the convulsions.
It will make the child more comfortable in every way. Secondly, it may
cure the patient. Third, it will be an aid to diagnosis. If pure blood is
obtained by lumbar puncture in amount more than could be explained by
"contaminated puncture" or if the blood flows as freely at the end as at the
beginning we are fair in assuming that there was free blood in the spinal
canal. The use of the spinal mercurial manometer will enable you to tell
with certainty the exact intracranial pressure. The normal intracranial
pressure of an infant is 2 to 5 mm mercury. The majority of these cases
will show an intracranial pressure of from five to twent>^-five millimeters of
mercury.
The findings in the spinal fluid are not constant. The spinal fluid may
be almost pure blood, and may be as much as two ounces in quantity. There
166 ■ NORTH CAROLINA MEDICAL SOCIETY
is an admixture of spinal fluid with the blood and you may get three or
more ounces in all. The spinal fluid may show no abnormalities, or it may
show only a few red cells with some broken down red cells. In some cases
you get an amber colored spinal fluid with hematin pigment. This I have
seen in two cases.
Case report. Case 1. E. C. R., ag-e 5 days, male, the result of the first
pregnancy, birth weight 6 Ibs.^ full term abnormal delivery. The mother
had eclampsia and just before delivery had one or two convulsions. The
labor was induced and took about fourteen hours. The labor was hard and
tedious and was terminated by the use of forceps with difficulty. The moth-
er's condition was so serious at the last that the life of the child was not
considered, for it seemed that the mother was surely going to die. At de-
livery the cord was around the neck twice and it was with difficulty that that
child was made to breathe. On physical examination the child was poorly
nourished and weak. He had a double cephalhematoma with two or three
forceps marks on the head. He had to be fed with the medicine dropper for
he would not nurse. Nothing unusual happened until the fifth day after
delivery when, at 3 P. M., the child had his first convulsion which was gen-
eral and lasted about five minutes. The other similar convulsions occurred
in the next hour. At 9 P. M. the child showed a bulging fontanel, a peculiar
pallor and a double internal strabismus. His knee jerks were active and
equal, and there was no Kemig's sign and no stiff neck. A lumbar puncture
was done and three cubic centimeters of fluid was obtained of which two
c. c. was pure blood. The spinal pressure reading was 15 mm. mercury.
The baby had a very good night, had no convulsions and nursed the mother
the next morning and continued to nurse her for 10 months. A lumbar punc-
ture was repeated each day for 4 successive days at which time the fluid
became clear and the pressure normal. He had an uneventful recovery and
at 12 months weighed 22 pounds. His mental and physical development has
been normal. He is now 20 months old and is normal in every way.
Case No. 2. 0. V., aged 3 yrs. 5 mos., female, the result of the fourth
pregnancy, the mother had one miscarriage at three months, two other
children living and well. The child was delivered of a breech presentation
with difficulty in delivering the after-coming head. Mother was in labor
from Wednesday 11 A. M. till Thursday 9 P. M. Twenty-four hours after
delivery the baby began having general convulsions at frequent intervals
continuing for 48 hours, having probably thirty or forty convulsions in that
time. For the first eight months of the baby's life she practically slept
very little, cried a great deal of the time. The child never nursed, was fed
modified milk with the spoon at first and when it would take the nipple at
three weeks of age it was started on the bottle. The feeding history was
not a rational one and may have accounted for some of the sleeplessness
and crying. Physical examination showed an undernourished and under-
developed child, color fairly good^ muscles soft and flabby. The child was
unable to sit or stand up, could use her legs and they were not stiff but
made no eff"ort to use them in walking. Her present weight is 20 lbs. 9 oz.^
her birth weight is unknown but she was an average size baby. Measure-
ments: height 33 in., circ. of head ISVs in., chest 19 in., abdomen 17 V2 in.,
right calf 6 in., left calf 5%. She cut her first tooth at 8 mos.. has twenty
now in good condition. She understands what is said to her but can say
Case I. E. C. R. Age 12 mos., wt. 22 lbs. A perfect baby.
PEDIATRICS 167
only one or two syllables. Her blood count and urine were normal. Spine
puncture showed 10 mm. Mercury pressure, while the fluid gave a negative
wassermann and a normal cell count. The retinal veins were engorged and
distended. There was no choked disc.
Case 3. N. M., male, 3 yrs., the result of the second pregnancy, the first
pregnancy resulting in craniotomy of child before he could be delivered, two
other living children well and healthy. All labors are hard and long, with
instruments. Chief complaint is stiffness of the legs and in ability to stand
alone or to walk without assistance. He was bom at term, birth weight
9% lbs., nursed his mother eight months then fed mixed diet. He sat up at
7 mos., talked at 18 mos., cut his first tooth at 8 mos., walked first at 19
mos., but never very well, and less well now than he was 6 months ago.
Physical examination shows a well nourished child, good color, muscles firm
with those of the lower extremity unusually firm. His knee jerks are very
active and equal. Eyes pupils equal and react to light and accommodation,
the disc is blurred and the veins distended and tortuous. He has a positive
Kemig's sign on both legs and a very active patella reflex. His gait is that
of a spastic diplegia. Measurements: height 38% in., circ. of head 20 ^/^
in., chest 22 in., circum. of calves and thighs equal, weight 36 lbs. Spinal
pressure was 20 mm. mercury, cell count normal, wassermann negative.
Case 4. M. D., aged 7 days, girl, premature, 7 mos., result of the second
pregnancy which followed eleven months after the first. The labor was
normal and the baby did very well, nursed well and had a pink color and
cried vigorously. On the fifth day the baby refused to nurse, had one or
two slight convulsions, became quite pale and stupid, but at times would
cry out. On examination the fontanel was tense, there was a double Ker-
nig's sign, no stiffness of the neck. Lumbar puncture gave an amber fluid
which registered 8 mm. mercury. On examination there were some broken
down red cells and twenty red blood cells, in tact, to each cubic millimeter.
The child died the following day, no autopsy obtained.
Case 5. J. L. W., aged 17 yrs., male, result of the first pregnancy, mother
was in labor three days, instruments used. At end of forty-eight hours the
baby began to have convulsions and three or four convulsions each day for
the first month. There are three brothers and two sisters living and well.
Past history, he had diarrhoea his second summer, has had jaundice twice,
no other illnesses. He has always been an unmanageable child, will not
work at one position more than two or three days. He has escaped from an
institution for the Feeble Minded three different times. He frequently goes
away from home three and four weeks at the time, sleeps in the woods and
either begs food or eats barks or roots and shrubs. When asked why he
does this he gives a simple grin and says because he wants to run away. On
physical examination he looks like a mental defective, his eyes are. dull and
vacant in their expression, has a thick skin and coarse, dry hair. He is well
nourished and has an unusually large nose. His temp., pulse and respira-
tions are normal. His blood pressure is 105 systolic and 50 diastolic. His
height is 67 in., weight 111 lbs. His spinal fluid gave a negative cell count
and negatvie Nogouchi reaction, the wassermann on blood and spinal fluid
was negative and his spinal pressure was 18mm. mercury. His optic disc
was pale and retinal veins were distended and tortuous.
168 NORTH CAROLINA MEDICAL SOCIETY
TREATMENT. In all cases of suspected birth hemorrhage a lumbar
puncture should be done for daignostic as well as for therapeutic purposes.
Repeated daily lumbar punctures until the spinal fluid is clear of blood is
indicated in these cases with the use of the Spinal Mercurial Manometer to
register the intracranial pressure each time. By this means you can deter-
mine whether the pressure has been reduced to normal as well as draining
off as much blood as may come by this route. After having done this, if
there are any focal signs, such as twitching of any group of muscles or eye
signs, as pappalitis or marked venous engorgement of the retinal veins a
decompression operation should be considered and a surgeon called. Though
I feel that it is wiser to call a surgeon with the first symptom that he may
better be able to advise as to the advisability of operation. The question of
an operation is an important one and if it is going to be done should be
done early, before the clot organizes, if we expect the best results. Up to
1914, only 17 decompression operations had been reported for this condition.
Of this number 7 recovered, four of these were operated on by Gushing
while others he operated on died.
Aspiration of the subdural space by puncture through the coronal suture
at the lateral angle of the anterior fontanel has been done by Henschen (6)
with good results. Giles (7) has reported one case cured by aspiration of
the subdural space or, as he called it, "Decompression Cranial Puncture.
More recently Dr. William Sharpe (11) of New York has operated on a
number of these cases and his results are as follows: Of twenty-seven
cases treated by (11) Dr. Sharpe, "nine had a cranial operation, four had
lumbar puncture drainage, while the others did not have a definite increase
of the intracranial pressure — so "latent" types — and recovered life without
operation or repeated spinal drainage. Five of these cases died, three fol-
lowing the operation. Unless the intracranial pressure is very high in these
newborn cases they should be given the opportunity of recovering life and
the greatest ultimate normality by repeated spinal drainage."
The advisability of an operation in these cases is a difficult one and will
have to be decided on the individual merits in the case. We know that
cases have recovered with only a lumbar puncture. Up to the present time
four cases have been reported cured by Lumbar Puncture. Brady (8) reports
three cases treated in this way with two complete recoveries. In 1916
Green (9) reported one case cured by Lumbar Puncture, and in the same year
Lippman (10) reports another case.
The importance of the early recognition of this condition can not be em-
phasized too strongly. In the beginning, if an operation should be done, it
should be done immediately if the best results are to be obtained. A Lum-
bar Puncture should be done on every case. It will not only relieve symp-
toms, but it may even cure the patient. The Spinal Mercurial Manometer
will accurately determine the intra cranial pressure.
Aside from the medical aspect, it is of economic value to the State that
these little fellows get a square deal at birth. The world is too full of
imbeciles, idiots, spastic diplegias, paralytics, epileptics and other less de-
fectives who are occupying our institutions as well as ai'e in our best fami-
ilies, who would probably have been normal, valuable citizens had they been
given a "square deal" at birth. Might Cesaerean section not be substituted
PEDIATRICS 169
for high forceps and the length of labor not be cut down by eariy intelligent
application of the forceps, when the mother's condition will warrant it ?
BIBLIOGRAPHY.
(1) Green. Boston Med. & Surgical Jr. Vol. CLXXII, No. 19, 1914.
(2) B. Sochs. J. A. M. A., Vol. XLVII, No. 19.
(3) Mouno. Archives Mensuelles D'Obste'trique et de Gynecologie. Aor.,
1915.
(4) Green. Boston Med. & Surg. Jr., Vol. CLXX, No. 18.
(5) Freeman, Rowland G.. New York.
(6) Henschen. Verhandt. Deutsch. Gesellsch f. Chir. 1912, Vol. 41, 271.
(7) Giles. Rev. Mens, de gyn., Vol. VII, P. 465-74.
(8) Brady, J. M. J. A. M. A., Vo. LXXI, Aug 3, 1918.
(9) Green. Boston Med. & Surg. Jr., 174,947, Jan. 29, 1916
(10) Lippman. N. Y. Med. Jr., 103, 263. Feb. 5, 1916.
(11) Sharpe, William. New York.
(12) Meara & Taylor. Arch. Ped., Nov., 1909.
(13) Currier, Andrew F. Med. News, Aug. 3, 1901.
(14) Sochs, B. J. A. M. A., Nov 10, 1906.
(15) Davis, E. P. W. B. Saunders Co., 1911, p. 483.
(16) Wai-wick, M. Am. J. Med. Sc, 158, 95, July, 1919.
(17) Vescher, A. L. Cor Bl. F. Schweiz Aerzte 49; 230. Feb. 22, 1919. Ab.
72, Apr. 19, 1919.
(18) Haynes Royals. N. Y. C.
DISCUSSION OF DR. SIDBURY^S PAPER
Dr. a. S. Hoot^ Raleigh : I think this is one of the most valuable con-
tributions to pediatrics that we have had in a good many years. I was very
glad indeed to see that Dr. William Sharp, of New York, who has done
more brain surgery on children than anyone else in this country, has, in a
recent article, given Dr. Sidbury credit for this method, and all of us, par-
ticularly the obstetrician and the pediatrician, should be more keenly on the
lookout for the symptoms of early intra and extra-dural hemorrhages.
Another thing, too, I think a great many of these cases that come to us in
later infancy with evidence of having sustained birth injury have not had a
hard labor or an instrumental delivery. A good many of these birth injuries
come to us with a history of having had a normal delivery. Any of these
cases that show the symptoms that Dr. Sidbury has pointed out ought to
have a lumbar puncture performed upon them, the diagnosis made, and the
treatment carried out as suggested.
*FOCAL HEMORRHAGIC ENCEPHALITIS.
(Report of a Case with Transfusion)
Aldert Smedes Root, B. S., M. D., Raleigh, N. C.
Much has been written within the past two years upon a disease to which
the various names "Encephalitis Lethargica," ''Influenzal Encephalitis,"
"Epidemic Encephalitis," "Epidemic Somnolence," et cetera, have been
applied.
170 NORTH CAROLINA MEDICAL SOCIETY
None of these terms seem appropriate. In case of "Encephalitis Letharg-
ica," as Bassoe (1) points out, — it is the patient and not the disease to
which "lethargica" refers. "Influenzal Encephalitis" suggests an etiology
which has not yet been proven. "Epidemic Encephalitis" and "Epidemic
Somnolence" are not definitely applicable, — for the malady may not prove
at all times to be epidemic in its occurrence.
Of those cases which have come to necropsy, — the pathology is constant —
consisting of small hemorrhagic foci in the midbrain, — hence the term
"Focal Hemorrhagic Encephalitis" seems a more correct one than any of
those which have been mentioned.
The etiology of focal hemorrhagic encephalitis has not been definitely de-
termined. Its coincident occurrence with influenza in both past and present
epidemics, has led most writers upon the subject to accept a definite relation-
ship between the two diseases, — if separate diseases they be. The general
concensus of opinion is, that focal hemorrhagic encephalitis is either a form
of influenza specifically affecting the brain, or that the toxins resulting from
influenza produce the lesions at a time subsequent to the acute attack, or that
an organism or virus different from that of influenza is the causative agent.
In the latter case, it is pointed out, many of these patients have recently
suffered from influenza so that their resistence is lowered, consequently
they are rendered more susceptible to the organism or virus causing enceph-
alitis. This would explain the coincident occurrence of the two diseases.
The preliminary report of Lowe and Strauss (2) indicates that the dis-
ease is caused by a filterable organism resembling that described by Flexner
and Noguchi in poliomyelitis. These they observed, when smears from the
mucus membrane of the nasopharynx of fatal cases were stained with Giem-
sas solution- The authors were able to transmit the disease to monkeys and
rabbits by innoculating them with Berkfeld filtrates of nasopharyngeal
washings.
Von Wiesner (3) of Vienna, announced that he isolated a globoid
diplococcus from a case of encephalitis and reproduced the disease in a
monkey by innoculating the animal subdurally with nervous tissue from a
fatal case.
Cleland and Campbell claim they have successfully conveyd the virus of
the disease to the sheep, the calf and the horse.
Mcintosh (4) of London, innoculated a monkey with material from fatal
cases which died with the symptoms of focal hemorrhagic encephalitis.
Flexner and other investigators have failed to find an organism in the
cerebro-spinal fluid or in the brain, nor have they obtained any definite re-
sults from innoculating monkeys with preparations of emulsified brain and
cord substances from individuals dying from the disease.
Flexner (5) in the March 27th, 1920, Journal of the American Medical
Association, writes as follows:
"It is still too soon to say whether or not we are now at the threshold of
the clearing up, by way of animal experiment, of the etiology and mode of
communication of this menacing disease, as was accomplished so recently,
and also by animal experiment, in the case of poliomyelitis. It is to be
sincerely hoped that we are. But at this moment, and while waiting for
PEDIATRICS 171
the ultimate and convincing experimental results, one need entertain no
doubt of the infectious and communicable nature of lethargic encephalitis.".
The pathology of focal hemorrhagic encephalitis is more or less constant.
The lesions consist chiefly of perivascular hemorrhages and infiltration of
the walls of small vessels with lymphocytes and plasma cells, — occurring for
the most part in the midbrain, — the pons, peduncles, the basal nucleii, the
aqueduct of sylvius, the floor of the fourth ventrical and the optic thalmus.
Less frequently the medulla and the white substance of the spinal cord are
affected. There is but little necrosis or tissue destruction
Of the cases reported by Neal (6), Tucker (7), Bassoe (8), Heiman
(9), Crookshank (10) and Barker, Cross and Irwin (11), a total of 138,
86 were males and 52 females. The ages were between 3 months and 55
years.
Symptoms: Many of the cases of focal hemorrhagic encephalitis reported
have not been preceded by an attack of influenza, — although a larger num-
ber have been, — an average duration of two weeks intervening between in-
fluenza and the onset of encephalitis.
The latter is manifested by a progressively increasing lethargy' and
asthenia, — frequently associated with cranial nerve palsies. This triad of
symptoms was first observed by French and English writers. The palsies,
however, are present in not more than 25% of cases. Slight fever is present
• — 100 degrees F. to 102 degrees F., and constipation is the rule. Headache
and diplopia are frequent symptoms in older children. The patella re-
flexes may be increased or diminished, — more frequently the latter. Rigidi-
ty of body and muscular tremors have been noted in a number of cases.
Signs of menigeal irritation, however, are usually lacking. (Brudzinski's
and Kernig's). Vomiting frequently occurs in the early stages. While
usually gradual, the onset may be sudden, being ushered in by a convulsion.
Slight optic neuritis may be present, — but not choked disk.
The most characteristic symptom is a disturbance of general conscious-
ness. There is first noticed mental apathy and drowsiness which becomes
day by day more pronounced until a state of coma is reached from which
the patient can be aroused but into which he soon falls again. The im-
mobility of features gives a peculiarly expressionless face. This comatose
state may last for several days, weeks, or months, when the patient either
gradually improves until entirely recovered, or recovers physically but is
left mentally defective, or death takes place.
The muscles paralyzed are more frequently those enervated by branches
of the 7th and 3rd cranial nerves, resulting in facial palsy or ptosis and
opthalmoplegia — external or internal (positive and bulbar nucleii.) These
palsies usually clear up entirely within two or three months' time, — if the
patient survives.
Laboratory Findings: There is present a moderate lencocytosis. Blood
cultures are negative. The cerebro-spinal fluid is clear and under slight,
sometimes considerable, pressure. The cell count is, as a rule, low in cases
seen late, 5 to 25, but higher in those seen at the beginning of the disease,
sometimes reaching one hundred. The cells are largely mononuclears. Al-
bumen and globulin are increased, and reduction in Fehling's is normal.
172 NORTH CAROLINA MEDICAL SOCIETY
Barker, Cross and Irwin (12), attaching much importance to the exami-
nation of the cerebro-spinal fluid, make this statement: "In our experience
a cell count in the cerebro-spinal fluid of from 10 to 100 small mononuclears
along with a positive globulin reaction with negative Wassermann and neg-
ative bacteriological smears and cultures is, at the time of an epidemic of
encephalitis, strong corroborative evidence of the existence of the disease in
a patient in whom the process is for any other reason suspected to exist."
Prognosis: The mortality according to the English Government Report
is about 20%, and this figure seems also to express fairly accurately the mor-
tality in this country from the cases thus far reported.
The course of the disease is within wide limits, varying from a few days
to several months. In a majority of cases, the course is protracted to 5 or
6 weeks or longer.
There is not enough data to form an opinion as to the percentage of pa-
tients who are left mentally defective. Two of Heiman's nine cases in
children, whose ages fell between 4 months and 13^ years, became im-
becilic. The treatment of the disease has been purely symptomatic.
The foregoing is a brief resume of the focal hemorrhagic encephalitis as
described by various authors up to the present time. The chief object of
this paper is to call attention to the striking result which the writer obtained
by transfusing a 15 month old infant who was suffering from the disease,
and for this reason the case will be reported somewhat in detail.
Baby A., female, age 15 months, was seen first August 16th, 1919. The
other two children born to the parents were living and well. The mother
has had no miscarriages. There was no tuberculosis in the family, nor any
exposure to it. The baby had not had influenza, nor any other disorder
prior to the present one. She was born at term, — labor having been nor-
mal, the birth weight being 8 pounds. She had always been well and strong
up to the present illness, and had developed as the normal baby should. She
sat up without support at 6 months of age, stood alone at 9 months, and
said 2 or 3 words at 13 months. She had been nursed every 3 hours from
birth (7 feedings), and recently had been having an ounce of whole cow's
milk after each nursing.
The present illness dated back 4 weeks, at which time the baby seemed to
be sleeping more than usual. No particular concern was felt over this un-
til the somnolence increased to such a degree that at the end of a week she
only aroused for her nursings and would immediately lapse into the coma-
tose state. She had remained in this condition up to the present time. There
had been little if any fever, no tremors or paralyses. She was obstinately
constipated.
Physical Examination: Weight 16^ pounds; height 30^ inches; cir-
cumference of head 18 inches; of the chest 16 inches. Color very pale and
skin waxy in appearance. Muscles flabby. Patella reflexes not obtained.
Anterior fontanella 2^x1^4 c.m. Eyes: negative, — no ocular paralyses.
Mouth : tongue heavily coated, corners of mouth excoriated from drooling
of saliva, six incisor teeth present. Ear drums: Negative. Physical ex-
amination of the throat, thorax, abdomen, liver, spleen, genitals and ex-
tremities, negative. Temperature normal. Blood: Red blood cells
2,600,000. Hb. 35%, White blood cells 5,000; Urine: Amber, acid, sp.
PEDIATRICS 173
gr. 1010. Albumen: Faint trace. Sugar: Negative. Diacetic acid, neg-
ative. Microscopic: 5 or 6 w. b. c. per field (low power), no casts.
Lumbar puncture was performed and 3 c. c. of clear fluid removed under
normal pressure. It contained two to five cells. Albumen: trace; Sugar
trace by Benedict's test.
The baby was observed for two days. It was with difficulty that she
could be aroused from the deep stupor. While undergoing a lumbar punc-
ture she lay with expressionless lace and closed eyes, the only evidence of
pain being shown by slight twisting of the body. On account of the marked
degree of anaemia, it was decided to transfuse her.
On 8-19-19, 60 c. c. of blood, obtained from the mother, in 7 c. c. of
2^% citric acid solution was introduced into the superior longitudinal
sinus. This blood was previously tested against that of the infant and vice
versa for hemolysis. After transfusion, the lips and fingernails became pink
and she nursed vigorously an hour later.
On 8-20-19, the day following the transfusion, the red cell count was
3,000,000 Hb. 43% and white blood cells 6,500. When seen this morning
she was sitting up in bed fingering toys. Her general appearance was very
much better. For several hours at a time during the day she was wide
awake, would grasp objects placed into her hand and make cooing sounds.
Her diet was regulated and she was sent home.
On 9-1-19, twelve days later, she was seen again. She did not seem
drowsy, but evinced little interest in anything. She did not follow objects
or sounds. Her physical condition was distinctly improved. The mother
says she is drowsy at infrequent intervals, and does not sleep much more
than she did before she became ill.
On 9-13-19, twelve days later, and twenty-five days from the time of
transfusion, symptoms relating to the nervous system were noted and had
developed rather suddenly on the previous day: — continuous spasmodic
twitching of the muscles of the left side of the face and right arm. Mouth
was held open and coarse tremor of tongue present and constant drooling
of saliva from corners of mouth. At frequent intervals gutteral sounds
were uttered. The lower extremities were unaffected. The weight was 17
pounds 2 ounces. Red blood cells 3,000,000; Hb. 50% ; white blood cells
7,000.
9-22-19, Tremors of face and arm were less marked. Dermatitis of face
from constant drooling. Baby does not notice objects or sounds. Hb. 55%.
10-11-19, Weight 18 pounds. Physical and mental condition improved.
Tremors less marked. She notices objects, takes watch in her hand and
reaches for mother. She cannot stand alone.
10-28-19, tremors have entirely disappeared. No further mental improve-
ment. She sits with mouth open and vacant expression. Cannot stand
alone.
1-8-20, physical condition improved, appetite good, bowels regular. No
tremors. No improvement in mental condition.
Summary: We have an infant 15 months of age, who, for 3 weeks, had
been in a state of profound somnolence, with no evidence of improvement
either physically or mentally taking place as time went on. She was trans-
174 NORTH CAROLINA MEDICAL SOCIETY
fused with blood from her mother (who had not had influenza), and a
striking improvement followed almost immediately, so that within a short
period of time she came out of the comatose state into which she had been
for so many days. Her appetite returned, she gained in weight, the blood
picture rapidly improved and the obstinate constipation was overcome.
All indications at the present time point towards the child's being men-
tally defective. Whether or not there will be a restoration of, or improve-
ment in, the mental faculties, — it is impossible to say. It is, however, hard
to disassociate the rapid and sudden betterment in the child's physical con-
dition from the effects of the transfusion.
201 N. Wilmington Street.
*Submitted for publication April 21st, 1920.
*Read before the Pediatric Section of the North Carolina Medical Socie-
ty, held in Charlotte, N. C, April 21st, 1920.
REFERENCES.
(1) Bassoe, Peter: Epidemic Encephalitis (nona), Jour, Am. Med. Assn.
1919. 72:677.
(2) Loewe and Strauss: Etiology of Epidemic (Lethargic) Encephalitis:
Preliminary note, Jour. Am. Med. Assn., 1919. 73:1056.
(3) Von Wiesner, R. Wien, Klin, Wchnsehr. 1917, 30:933.
(4) Forty-eighth Annual Report of the Local Government Board, 1918-
1919. Medical Supplement, London, 1919, p. 76.
(5) Flexner, Simon: Lethargic Encephalitis: History, Pathologic and
Clinical Features, and Epidemiology in Brief, Jour. Am. Med. Assn.,
1920, 74:865.
(6) Nea'l, Josephine B.: Lethargic Encephalitis, Arch. Neurol, and Psych.,
1919. 2:271.
(7) Tucker, B. R.: Epidemic Encephalitis Lethargica, or Epidemic Som-
nolence or Epidemic Cerebritis, with Report of Cases and Two Necrop-
sies, Jour. Am. Med. Assn., 1919. 72:1448.
(8) Bassoe, P.: Epidemic Encephalitis (nona). Jour. Am. Med. Assn.,
1919. 72:971.
(9) Heiman, H.: Post-influenzal Encephalitis, Am. Jour. Dis. Ch., 1919.
18:83.
(10) Crookshank, F. G.: Brit. Med.' Jour., 1918. 2:489.
(11) Barker, Cross and Irwin: Am. Jour. Med. Science. 1920. CLIX: 157.
(12) Barker, Cross and Irwin: Am. Jour. Med. Science, 1920. CLIX: 337.
DISCUSSION OF DR. ROOT^S PAPER.
Dr. I. W. Faison, Charlotte: That is a splendid paper of Dr. Root's,
and he deserves a great deal of credit for handling it as he did.
I just rise to ask one question. There is one phase of the matter into
which I would like to go a little further. I would like to ask him to ex-
plain the transfusion, what he expected from it and why did he give it?
Dr. J. BuREN SiDBURY, WiLMiNGTON: There is one point that I
noticed in a few of the cases that I have seen in the hospital. I do not
PEDIATRICS 175
think it has any significance in regard to the therapy at all, but most of the
cases have an initial onset of temperature to 102 or 103. Then the temper-
ature comes down and stays at an absolute level. It ocmes down to 98 and
stays there. The temperature is absolutely level unless some complication
arises. I do not think that it has any significance, but I wish to cite it as a
point that I have noted.
Dr. Root^ closing the discussion: I gave the transfusion on account of
the extreme degree of anemia in this case. I merely hoped to carry the child
further along, until the disease ran its course. Just how the transfusion
produced the marked change in the baby's condition I do not know. I did
not speculate on that in my paper. It may have operated in several ways —
possibly through the introduction of anti-bodies. Possibly the course of the
disease was at an end, but that seems improbable on account of the sudden
betterment which took place immediately after transfusing.
ACIDOSIS.
Dr. L. W. Elias, Asheville
A year ago, an intelligent, well equipped North Carolina practitioner
was questioned regarding Acidosis in his part of the State. Replying he
asked, "what is it?" In the belief that his case was not an isolated one,
this paper was written. In further apology let it be stated that it is entirely
immaterial to the writer whether Acidosis is called a disease, a symptom a
symptom-complex, or what not. This is cheerfully left to individual prefer-
ence. For the sake of clearness, statements will be made rather dogmatically.
Three points are considered: (1st) Attention is called to a clinical con-
dition, the recognition of which is fairly recent. (2nd), is considered its
diagnostic features, and, (3rd) is a discussion of the measures employed for
relief.
Acidosis exists when acid is increased in the human system, and the base
reserve is decreased.
All body fluids and tissues are kept in a slightly alkaline condition. This
reaction is most carefully guarded. When the metabolism of food or the
breaking down of tissue liberates acids, the alkaline stabilizers are worked
constantly to prevent a disturbance of the normal alkaline reaction.^ The
means employed are oxidation of acid products into carbon dioxide, which
latter is eliminated through the lungs- Some acid is thrown out bodily
through the kidneys; more is eliminated through the kidneys after first being
neutralized by the body bases. These bases consist of sodium, potasium,
magnesia, calcium, and amonia. The amonia on its way to form urea is
diverted to neutralize acid. This is Nature's normal method of maintain-
ing a constant alkaline reaction in the body. If acid is introduced into the
body, or develops in excess, then an increased demand is made upon the
bases of the body, and the body begins to lose its base reserve. If this is con-
tinued, there is of necessity a decrease of that alkalinity of the tissues, which
is absolutely essential to the proper maintenance of life and body activity.
An acid condition of body fluid is never reached, but as acid accumulates
and base is exhausted, in attempting to neutralize the acid, a less alkaline
condition is approached. This condition we speak of as Acidosis.
176 NORTH CAROLINA MEDICAL SOCIETY
The manifestation of Acidosis will be considered in a moment. But
first arises the question what causes this disturbance of normal function to
such an extent that the body is no longer able to maintain its usual alkalini-
ty ? This is a problem 3'et almost wholly to be worked out. We know that
with pneumonia and numerous other diseases, we may have acidosis. We
know that with summer diarrhoea we frequently have it. Here, a loss of
water from the body is probably one of the factors, acting by reducing kid-
ney elimination. We may also have it in chloroform and ether anesthesia,
and in a number of other conditions. The exact way in which these dis-
eases and conditions operate to produce Acidosis is very imperfectly under-
stood, or not understood at all.
Besides the above, we have the condition of Acidosis coming on apparently
out of a clear sky, when we are absolutely unable to find any cause what-
ever. It is to this type that I wish to call particular attention, as it is this
type which is not so well recognized, and, by some of even the best men, its
very existence is denied. And yet the symptom-complex is distinct enough
so that when stated those who have never noticed it before will probably
recall some cases, or at any rate will observe them within the near future.
For this condition is not rare, and once one has his attention called to it, he
is sure to meet cases in his practice.
To illustrate this condition, take a typical case. A little two-year old,
who is a well developed, carefully fed, normal child, apparently in the best
of health, and with no past history bearing on the case. Suddenly he begins
to vomit without rhyme or reason. He seems languid and dull, and on being
disturbed is irritable. He vomits, usually only on taking food or water.
Thirst is pronounced. The skin slightly flushed, and he seems to have fever,
but the thermometer shows but a slight elevation, usually not above 100 or
101 degrees. There may be a few stools of fairly normal appearance. The
breath has an odor suggestive of chloroform. The urine gives a strongly
acid reaction to litmus. The breathing, which is one of the most important
diagnostic points, is the deep "air-hunger" type rather than rapid. In the
case just mentioned, this may be so slight that it is not noticed. When it is
present in a pronounced degree, the patient has reached an advanced stage
of acidosis, and the condition is grave indeed. A careful physical examina-
tion of ears, throat, chest, abdomen, skin, blood and urine fails to reveal any-
thing that might suggest a cause of the trouble. And when one who has had
a number of cases, finds such a condition, and careful examination reveals
no cause for it, he says the patient has Acidosis. And because the outcome
in any particular case is almost more uncertain than anything in medicine,
the doctor is guarded in his prognosis.
The symptoms enumerated above may vary in degree. Vomiting may be
excessive, or absent. The listlessness slight or amount almost to coma. The
odor of the breath slight or heavy, pervading the entire room. The thirst in-
tense or moderate, etc. But the above picture is fairly characteristic of the
average case.
This condition may right itself without help, presumably because what-
ever produced the trouble ceases to operate, and the system has not suffered
PEDIATRICS 177
sufficient damage to prevent readjustment of itself unaided. On the other
hand, the condition may grow worse, and the dullness increasing the urine
remaining persistently acid in spite of large doses of sodium bicarbonate,
many times the amount which in health would render the urine alkaline.
The dyspnoea becomes pronounced, and death supervenes quietly, or sud-
denly, with the patient apparently in a state, of profound exhaustion. Death
usually occurs in from twenty-four hours to four or five days.
Diagnosis: The diagnosis is made by the nausea and vomiting and thirst,
with disturbed respiration of the "air-hunger" type, with listlessness, or
stupor. Confirming the diagnosis is the persistently acid urine after large
doses of alkali. In the light of repeated clinical experience the above con-
ditions, without any cause which the most careful examination will reveal,
justify a diagnosis of Acidosis.
The symptoms may all be so slight that one is in doubt as to whether or
not he is dealing with Acidosis, and it may take careful watching to decide.
However, valuable time need not be lost, since one of the important means
of treatment is also a most important measure for diagnosis. This is the ad-
ministration of sodium bicarbonate. In doubtful cases give one-half drachm
of soda in one-half oz. of water every hour. In the average baby 30 grains
will render the urine alkaline. If after two or three doses the urine still
remains acid, we are justified in calling the case Acidosis.
Treatment: Once the diagnosis is made, most energetic measures should
be instituted, for, as above stated, no one can say which case will resist, and
which yield easily to, treatment. So we dilute the acids with water, which
also assists the kidneys to eliminate acids. We further combat the acid, and
at the same time restore lost base, by giving sodium bicarbonate, preferably
in large doses given at short intervals; at least Yx dram every hour. If this
is given in sufficient amount, we check the condition, possibly bringing it to
a standstill. The acid is being neutralized, the depleted base reserve is be-
ing replenished. But in many cases this is not sufficient, and without carbo-
hydrate the patient will slip back into his former condition, and go pro-
gressively bad. Hence carbo-hydrate is imperative. If it must be injected
into the body, it is given in the form of glucose, a 5% to 10% solution.
When vomiting has subsided the starches are used. At times they act in re-
lieving nausea.
Our treatment then, consists of water, sodium, bicarbonate and carohy-
drate. These are not given consecutively, but in practice they are given
more or less simultaneously, either by mouth or Murphy drip or possibly
by the skin, in the vein, or in the peritomeal cavity.
Large amounts of water are needed, and where vomiting is excessive and
the bowels irritable, the intra-peritoneal route presents the most satisfactory
way of introducing it into the body, giving 150 to 400 c. c, with or without
5% of glucose and with or without 2% of sodium bicarbonate. This is
repeated in 4 to 6 hours. The veins also are used for the soda and glucose.
But, except in the presence of great abdominal extension, the peritoneum
should be used for the solution, since the large amounts needed, if given in
the vein, would throw too great a strain upon the circulation.
Conclusions: 1. Acidosis is a condition caused by an increase of acid,
and a loss of the base reserve of the system.
178 NORTH CAROLINA MEDICAL SOCIETY
2. This may follow disease, or other known abnormal conditions.
3. There are cases, by no means rare, where the symptoms of Acidosis
are preceded and accompanied by nothing discoverable, which might be con-
sidered as a cause.
4. The treatment consists in getting into the system large amounts of
sodium bicarbonate, carbohydrates and water, in every way possible, and as
quickly as possible.
Dr. a. S. Root, Raleigh : I was very much interested to note how Dr.
Elias was going to differentiate between cyclic vomiting and acidosis. I
have not yet found any one who has been able to discuss that to my satis-
faction. I think that we are all somewhat mixed up on acidosis. Dr. Dunn,
of Boston, considers cyclic vomiting, or recurrent vomiting, as a form of
acidosis. Dr. Howland, of Johns Hopkins, considers a case to have acidosis
where the hydrogen-ion concentration of the blood is increased and the CO
tension of the aveolar air is decreased. That is the border line that he draws,
but it is impossible, in a practical way, to make that distinction. Clinically,
Dr. Howland considers cases that have hypnoea as cases of acidosis. These
cases of recurrent vomiting alwaj^s have diacetic acid in the urine, and I am
not at all sure that this is an accompaniment of cyclic vomiting, or whether
it is the result of starvation, because in a majority of these cases you do not
find diacetic acid in the urine when the vomiting begins, but you will always
find it the day afterwards.
Dr. I. W. Faison^ Charlotte: This is a subject that has been forced
on me during the last six months by two very close and very interesting
cases. I wish to mention first what Dr. Root had to say as to cyclic vomit-
ing. It would look as if the cause of all these conditions is the sheet anchor,
or what you mean by acidosis. We know that a child can have acidosis f ram
too frequent bowel movements, acidosis from constipation as the cause, also
that it can come from any type of infection. Another cause brought out at
the Southern Medical Association meeting at Asheville, which interested
me much, by Dr. McGuire Newton, of Richmond, was that four cases of
cyclic vomiting had a cause behind it of an organic appendix. I had one of
the same type, which was operated, and so far the cyclic vomiting has not
reoccurred. It is well to consider that, it is well to go into the appendix be-
fore you go by a case of cyclic vomiting. Starvation, continued vomiting,
or diarrhea following these acute attacks of cyclic vomiting, the cause be-
hind which is the lockup of an organic appendix.
Now, as to Dr. Elias' paper, which is pretty thorough, we can look back
and try to make the diagnosis from the history of the first few days prior to
the attack. The child is put on the train, is traveling for a day or two, his
diet changed, and on the second day he has acidosis. Now, what was the
cause ? Taking away the carbohydrates and putting him on eggs and milk.
The protein diet is the cause of the acidosis. It does come on suddenly, they
do vomit, they suffer for water and air. The picture is distressing, it is
awful to look at. There is no more distressing condition, to my mind, than
this one of puerperal eclampsia. First we hear the patient beg for water
and beg for rest. It tries a man's soul.
As to the treatment, I cannot say much, for I have only five minutes. I
have had peculiar things come up in that line. I had a patient in this same
PEDIATRICS 1 79
condition, awful hyperpraea and thirst. She had been treated by no less
great man than Dr. Barker of Hopkins, so I asked her what Dr. Barker
did for her. She told me that he gave her soda, and I did exactly what he
had done. Less than twenty-four hours afterwards I ran across Dr. Barker
and told him what I had been doing, that I had been giving her soda, as she
said he did. He said that they had quit soda as a curative, that it would not
cure acidosis. It is well enough to give it, it does not hurt. If you have a
baby you have to rely on the stomach to take it. Do not get his rectum dis-
turbed. So far as curing, it is not worth anything. The remedy is glucose,
dextrose. I came in close conference with Dr. Howland in consultation
over the other case. He said, "Do not give soda unless he will retain it. If
he vomits do not put anything of any nature in his stomach. Put six ounces
of ten per cent glucose dextrose in the rectum every six hours and wait. If
that does not cure him, he will not be cured." I got a Murphy drip at once,
put the catheter well up into the colon and took about one and one-half
hours to give him six ounces by the drip method. The hj'perpnoea began to
give way, the stomach relieved, the child began to take water, and we gave
him water, and after twelve hours of absolute tie-up of the kidneys he passed
water. When that happened I felt absolutely sure that the child would get
well, and he did get well. It is the fats especially and the proteins that pro-
duce the greater majority of these cases. There is an excess of fat or pro-
tein metabolism. The metabolism of the child was so changed that this con-
dition was killing him. Therefore, change that and put in the sugar. For
daj's and days this child had no fats or proteins of any description, but kept
on sugar and corbohydrates. So, in the handling and treatment of acidosis,
soda will hold them for a day or so, but it does not cure.
There are no authorities for me in medicine — there are consultants and
advisors — they may and do change their minds.
Dr- Horace M. Barker, Lumbrton: As to the point which Dr.
Faison brought out regarding the protein side of it, I have found in a num-
ber of cases that these cases that periodically have a spell of acidosis, cyclic
vomiting, etc., do show in a number of cases a marked idiosyncrasy. In fact,
I have one case now that has a marked idiosyncrasy to onions. By eliminat-
ing that one protein, that case has gotten on splendidly. The eliminating of
the protein is one of the many factors.
Dr. J. Buren Sidbury, Wilmington, N. C. : I think that Dr. Faison's
talk emphasizes the fact that until you have a specific therapy you have a
multitude of therapies. The three points that Dr. Elias brings out, first, all
the water the child can take by mouth ; second, hypodermoclysis or intra-
peritoneal injection of normal saline or dextrose and soda ; thirdly, soda
bicarbonate to the point of neutralizing the urine. As much as two thousand
c. c. of fluid in twenty-four hours should be administered if possible.
Food is of secondary importance and should be delt with accordingly.
This is a condition which is going to do its work in a short while and if the
child does not get any food it will be better than attempting to give food
which may aggravate the condition.
Dr. Elias, closing the discussion: I am exceedingly grateful to you all fo:-
this illuminating discussion. It brings out the state of mind in which th^
profession is at present. There is no uniformity of opinion here, neither i*"
180 NORTH CAROLINA MEDICAL SOCIETY
there in the mind of any individual doctor. There must be a multitude of
causes. I recently lost a case that had for two weeks previously had a dram
of soda every day. The mother was giving it for some little skin eruption.
The child had had very careful diet, with no variation of any sort, but the
soda was not worth a cent. On the other hand, there is a doctor at home
who has two children who have had two attacks each, and he attributed it to
eating tod large an amount of crackers. There was no indigestion, but they
had a marked attack of acidosis. There are dozens of other cases, and they
violate every theory that you can formulate. There is no theory that is sat-
isfactory. I have been recently up to the Surgeon General's library and to
Baltimore and other places, and you can find as many theories as there are
doctors. There is no uniformity as to the causes nor as to the treatment.
Some say it is due to colloids, some say that is all poppycock. There is ab-
solutely no uniiormity, but one thing that I want to emphasize is that this
condition must be recognized. I think it is high time that we are recognizing
this thing and not waiting for the hypertony, which they say is the only diag-
nostic point. When a child gets to that point he is mighty sick, and there are
very few chances for the average case, in my limited experience. Learn to
recognize these cases before they reach that stage. Early recongition is the
important thing.
I think everybody is agreed that there is a loss of bases. When that is lost
we are bound to have a disturbance of the system. It is largely theoretical,
but it is theoretically accurate to give something to restore this lost base, and
we do get relief in some cases.
Now, as to the way of giving water, the intra-peritoneal injection is the
ideal thing. You can inject it into the abdomen, giving all the way from 150
to 300 c. c. of normal salt solution. You can put glucose into it, and it can
not be rejected. So give the water. If you give it into the vein you will
overwhelm the circulatory system. Give it in the abdomen and it is soaked
right up. Take a needle and inject it just below the navel. It is practically
impossible for the intestine to puncture. You can repeat it every four to six
hours, and if you observe proper asepsis you can give it with practically no
danger whatever.
The discussion as to whether a person has acidosis or cyclic vomiting does
not mean a thing, to my mind. It does not count for a thing. There is no
way yet of deciding. But there is a clear cut condition of which babies are
dying, and that is acidosis. It comes on out of a clear sky, they vomit, are
restless and dull, and the babies die. There are three things today to give
them — soda, which helps for a short time, water, and dextrose, and then
you are doing the whole thing at once.
INFECTION OF THE NEW BORN.
Dr. Yates W. Faison, Charlotte^ N. C.
Not only must the new born infant combat diseases particularly encount-
ered at this early stage of life, but he must also fight diseases that commonly
effect other children.
We usually think of the young baby as being immune to the common con-
tagious diseases, but we know that they do occur.
PEDIATRICS 181
Scarlet Fever has been reported in a new born infant — Diptheria is rather
uncommon in young infants, but all infants are susceptible from birth ex-
cept those whose mothers have immunity. Uusually infants under 2 months
of age are immune to Measles, but here again it seems that only those in-
fants are immune whose mothers have had the disease.
Measles has been reported as soon as sixteen days of age.
Whooping Cough has been reported as early as the fourth day with dis-
tinct whooping by the eighth day.
Besides these, the infant may suffer from any of the common infectious
diseases — Influenza, Typhoid Fever, Pneumonia, etc.
Again we see various infectious conditions caused by the various pyogenic
organisms — I will only mention ophthalmia neonatorum, tetanus, and
pemphigus neonatorum, as they are usually, considered separately.
In some of these infectious conditions, there is only a localized external
inflammation, more often ending in abscess formation.
Omphalitis, or inflammation of the umbilicus and surrounding cellular
tissues is probably the most common — Occurs any time until the umbilicus
has cicatrized — Usually terminating in abscess formation.
Erysipelas may be a complication of the inflammation about the umbilicus
or may start from any abrasion of the skin at any part of the body — Usu-
ally spreads widely — Generally involves only the superficial tissues, but
may involve the deeper tissues and cause diffuse suppuration. The symptoms
are very severe and usually terminates fatally.
Multiple superficial abscesses may occur.
Sometimes one or more of the internal organs are affected, without ex-
ternal manifestations. We might include in this type the umbilical arteritis
and phlebitis cases.
The arteritis occurs much more frequently than the phlebitis. The um-
bilicus may show nothing abnormal, but on pressure pus may be expelled
from the vessels. The vessels may be involved only a short distance or
may reach all the way to the liver. The arteritis is complicated by the usual
lesions of a pyemic infection, the phlebitis is usually accompanied by intersti-
tial changes in liver or multiple liver abscesses. The patients usually show-
• ing jaundice.
Pneumonia is not at all uncommon in the new born. Usually of the
broncho type, the processes appearing more often in the upper than in the
lower lobes. The symptoms are often obscure and the physical signs indefi-
nite. There is found at autopsy some involvent of the lungs in most of the
fatal cases of pyogenic infection.
Peritonitis is a common complication of an umbilical arteritis or erysipelas
in fact it is one of the most common complications of pyemic infection and
very often the cause of death. It may be local or general.
Meningitis also occurs as an acute purulent process, associated with meni-
geal hemorrhages, acute encephalitis, and multiple abscesses in the cortex. A
positive diagnosis can generally be made by lumbar puncture.
Acute suppuration of joints may occur early or late. The smaller joints
are more frequently involved than the larger ones, but any joint in the body
182 NORTH CAROLINA MEDICAL SOCIETY
may be attacked. The organism most often found is the gonococcus, next
the streptococcus.
Pyelitis has been found in the new born.
A case was reported where the appendix was successfully removed twelve
hours after birth. And finally there occurs cases of general infection, true
septicemia or pyemia, associated with multiple abscesses in the viscera, joints,
or cellular tissues. This is a particularly common manifestation of infection
of the new born, and it is to this type that the term "Infectious Disease of
the new born," is commonly applied. I will consider this condition in more
detail and then report a case. Infection occurs when micro-organisms are
brought to any portal of entry, which is open in a new born child whose
resistance is too weak to prevent their entrance. Dunn thinks that the most
important factor in the occurrence of the infection in the new born is the re-
latively open condition of certain portals of entry, particularly the umbilical
wound. He thinks that if the low general resistance of those infants was
such a big factor, infections would be relatively much more common.
The organisms may enter through abrasions of the skin or mucus mem-
brane, the mouth, lungs, or umbilicus, the last one being by far the most
common one. The stump of the cord is undergoing a necrotic disintegration
thrombi are found in the umbilical veins which may easily become infected
and then break down into purulent material. This material may then enter
the circulation and produce a general infection. All these processes may go
on without any lesion being noted at the umbilicus. The infection may take
place before or after the separation of the cord.
The infection may come in rare cases from the vaginal secretions or the
mother's milk. Although it has been shown that in the great proportion of
cases the milk of a mother suffering from septicemia contains pyogenic
organisms, still the taking of these into the stomach is not likely to infect the
infant. Other sources of inocculation are unclean hands of nurse or physi-
cian, improper care of umbilicus, dirty bath water and dirty clothing.
In rare instances septic infection may be transferred directly from an in-
fected mother to the fetus through the placental circulation.
The micro-organisms chiefly concerned in these infections are the common
pyogenic bacteria, staphylococcus anreus and streptococcus. Next in impor-
tance comes the gonococcus and pneumococcus.
The clinical manifestations are many and varied. The three most com-
mon symptoms are fever, jaundice, and hemorrhages.
There is usually a sudden rise of temperature followed by an irregular
septic temperature. After a period of such fever, the temperature in some
cases becomes normal or even remains permanently sub-normal.
Jaundice may or may not be present. In the severe cases it is intense. It
is not of the complete obstruction type, but bile is found in both urine and
stools. Hemorrhages are common and may be the cause of death. They may
come from the umbilicus, intestine, or any mucus membrane- Purpura is
the most common hemorrhagic manifestation.
Nervous symptoms are generally present. Prostration is generally mark-
ed and extreme exhaustion may come on rapidly. These symptoms vary
from restlessness or apathy to convulsions or stupor.
PEDIATRICS 183
The pulse is rapid and weak. Diarrhea is frequent — vomiting is less com-
mon. Wasting is usually present and rapid. In addition there are symptoms
and signs due to the various forms of local inflammation — localized abscess-
es, peritonitis, meningitis, pneumonia and erysipelas — these may be so pro-
nounced that they obscure the more serious general infection. On physical
examination the liver is usually found enlarged — the portal of entry may or
may not be found — the umbilicus may or may not be inflamed, the umbilical
depression may be filled with pus, or pus may be made to exude by pressure
about the umbilicus.
The blood examination usually shows a marked lencocytosis. Only by a
blood culture can the diagnosis of a general infection be definitely proven.
The prognosis is always bad, even in the mildest forms — and the severest
types almost alwaj's die. It is probable that practically all cases, in which
there is a general sepsis or any important visceral lesion, die. Only patients
with localized inflammation, such as those of joints or skin, are likely to re-
cover. A few cases of apparent umbilical infection recover, but it is probable
that in these cases the septic process never become general. Death may occur
within a few days or may be delayed for a longer period.
Pyogenic infection of the new born, just as puerperal fever in the mother,
is preventable. This is shown by the great diminution in its occurrence
since the introduction of aseptic methods into obstetric practice. In the vast
majority of cases this disease is due to the carelessness of an attendant, the
physician, the nurse, or the patient. — Clean clothes, clean hands and clean
surroundings for the baby are essential. The umbilical wound should be
treated like any clean wound — dressed with sterile dry dressings and every
thing that comes in contact with the wound should be sterile.
Unfortunately our treatment is limited. Mostly symptomatic. Wherever
there is localized suppuration, incision, evacuation and drainage should be
done.
The childs general nutrition should receive careful attention by closely
directing the details of nursing and feeding. An autogenous vaccine can be
tried where it has been possible to isolate the infecting organisms — but as yet
no favorable reports on its use have been made. I believe that transfusion
in these cases offers us the best hope of benefit, as it has proved in puerperal
sepsis in the mother. I will now report a case.
This baby was brought to me on January 28th when he was two weeks
old. Father living and well except for occasional attacks of supposedly gas-
tric ulcer. Absolutely denies buetic infection. Two older children living
and well. No history of tuberculosis on either side. The mother on the
second day after this child was born began a rapidly rising temperature,
which turned out to be a streptococcic puerperal infection, from which she
died in a few days- The delivery was normal in every respect and directed
by a careful physician and nurse. The child appeared and acted in a normal
manner — weiq;hed eight and one-half pounds. Navel cared for in usual
way. Was given boiled water for twenty-four hours, then put to mother's
breast. After third day was put on artificial feeding (Dryco Dried Milk,
I believe) because of the mother's febrile attack and lack of milk in breasts.
One or two other foods were tried during the next two weeks — due to in-
fant's "apparent inabilitj^" to digest them.
184 NORTH CAROLINA MEDICAL SOCIETY
On the fifth day there appeared a swelling in the first phalanx of fourth
finger of left hand. The swelling was symmetrical, reddened and tense. At-
tained the size of a hazel nut. Absolutely no temperature or other symp-
toms. The following day a like swelling appeared around and including
apparently the left elbow — exactly the same characteristics and symptoms
except the baby resented having the left arm moved. Cord came off on the
seventh day and appeared normal. In three days both swellings began to
decrease in size. The color became a dusky red, as if the tumors contained
old blood. They became reduced about one-third in size and remained so
up to the time I saw the baby.
Five days after the first swelling on finger was noticed, the scrotum was
found to be swollen and rapidly attained the size of a large orange. On
the same day a like tumor appeared over the right clavicle, about the inner
third, about the size of an egg. Both swellings had the same appearance
as previous ones, first tense, pinkish, oedenatous, then lessening in tense-
ness and becoming a dark red color and reduction of one-third to one-half
original size. The baby had not yet shown a bit of fever. Temperature
ranged from 98.5° to 99.5° rectal.
No other symptoms developed except the feeding had not progressed very
satisfactorily. The baby had lost only about one pound since birth. I saw
the baby on the fourth day after the swellings in the scrotum and over the
right clavicle appeared.
He was well developed, color good, did not look as if he had lost but very
little weight — weighed seven and one-half pounds — cried lustily, but took his
food very slowly. Did not look like a sick baby. Head, eyes, mouth and
throat negative. Heart and lungs normal. Abdomen soft. No tenderness
or rigidity. No masses. Umbilicus showed no redness or induration, slight-
ly moist masses could be expressed from umbilical vessels — liver palable about
three cm. below costal border. Spleen not palable — lower extremities nega-
tive. Anus negative. Glands in groins and axilla palable. Skin clear. There
was a swelling directly over the middle of the right clavicle about the size
of a half lemon — slightly reddened, tense, with a very slight sense of fluctu-
ation. It looked very similar to an angio neurotic oedena swelling.
There was a like swelling over the left elbow, spindle shaped, extending
for an inch above and below. Seemed to give pain on motion. There was
also a swelling over the first phalanx of fourth finger on left hand — here the
color was a darkened red as if old blood was under the surface — more fluctu-
ation than the others.
The fourth swelling was in the scrotum which was about the size of an
orange of a dark red color like the finger, tense, but showing slight fluctu-
ation. Rectal temperature 99°- Pulse 140. Respirations 30. Urine nega-
tive except for slight trace of albumen. Stools were light yellow — full
of undigested food — some mucus — four to six dkily- Blood — white blood
count — 65,000 — smear showed Polynuclears 64%. Mono nuclears 36% —
no normal cells.
The diagnoses suggested were Pyogenic Infection, Sj^philis, Tuberculous
Infection and a Hemorrhagic condition.
As three of the four swellings had occurred over or about the bones, x-rays
were taken, which showed the swellings not in the bone but in the soft tis-
PEDIATRICS 185
sues. So here we had an infant whose mother had just died with a strepti-
coccic puerperal infection, not sick looking but fairly well nourished, with
swellings appearing at intervals over different parts of the body, with none of
the ordinary symptoms of a pj^ogenic infection as high temperature, prostra-
tion and wasting — in fact he had shown no temperature, but had a white
count of 65000.
I decided to puncture these swellings and see what they contained. The
swelling over the clavicle was selected and at first obtained nothing, but on
pushing the needle deep in, thick, old pus was drained up into the syringe —
in turn each swelling was punctured and each one contained pus. A bacteri-
ological examination of this pus showed a pure culture of streptococci — im-
mediately each swelling was incised, evacuated and drained — it was surpris-
ing to see the amount of pus — the tunica vaginalis on either side was filled
— at least two ounces was drained from the elbow.
The baby was put on a weak cow's milk mixture to which Dextri Maltose
was added in two days. It was taken well and the stools began to look more
normal a once. By some misunderstanding the autogenous vaccine ordered
was never completed. The second day after entrance another abscess ap-
peared over the sixth rib, left side, anteriorly, which was immediately
drained.
On this day the baby began to run its first temperature — 100°-100>4
rectal. The third and fourth day passed without any new development ex-
cept for the fact that the baby seemed to be brighter and improving. All the
wounds were draining only slightly and looked as if they were healing. The
chances at this point looked bright for recovery. But on the morning of the
fifth day the temperature was runnin^^ between 102°-103". The baby
was restless, looked sicker. Physical examination revealed two things. A
rather indistinct swelling was barely to be made out at the edge of the liver
in about the nipple line — no jaundice. Also the abdomen had become a little
spastic and distended and seemed tender. The symptoms became rapidly
more severe. The child became prostrated — would take no nourishment —
circulation collapsed requiring repeated stimulation. The abdomen became
extremelv distended, hard and spastic, especially over the upper portion.
Temperature 104°-106°. The baby died that night. The baby had un-
doubtedly developed a peritonitis, with possibly a liver abscess. Autopsy
was denied.
This was a pyogenic infection of the new born, probably pyemic in type.
The portal of entry was obscure. At first showing only manifestations of
suppuration in the cellular tissues, with one joint involved with none of the
common severe symptoms, then a period of apparent convalescence after the
incision of the abscesses, and finally a sudden appearance of a visceral lesion,
certainly peritonitis and possibly liver abscess, with sudden death in twenty-
four hours. The question of the portal entry is of some interest. No abras-
ion of skin or mucus membrane was ever found. Although we know that
when no other point is to be found the umbilicus is probably the source
whether or not there is any sign of inflammation — yet in this case it might be
a question — since the infecting micro-organism was the same in both
mother and baby and as her infection showed up so soon as the second day,
it is not inconceivable that the bacteria was present at time of delivery and
was ingested. Again, as the baby was nursed three or four days after the
186 NORTH CAROLINA MEDICAL SOCIETY
sepsis Started in the mother, it could be one of the rarer cases where the
bacteria entered through the milk.
The course of the case was some what out of the ordinary — ordinarily it
would be hard to conceive of a new born infant, with an infection of this de-
gree and accumulation of so much pus, never running any fever except at the
terminal stage. And 1 shall be frank to say when I first saw the baby, the
explanation of the different swellings was puzzling. Again, it seems strange
that the absorption, which must have undoubtedly been going on in the pres-
ence of so much pus and for at least two weeks, did not show more general
symptoms — there was no primary reaction of fever and then falling to sub-
normal because of overwhelmed resistance.
Another point brought out by this case is, that we must keep in mind that
every infection of the new born, no matter how slight or mild a degree, must
be considered a serious condition. I almost made the mistake of letting the
father return home on the fourth day after I saw the baby; yet in twenty-
four hours the baby was practically dead from a complicating visceral lesion.
Always give a guarded opinion. And finally I wish to enter a plea for more
careful and closer watching of the new born baby. We see it too often that
the physician considers his duty done when he has seen the delivery through,
tied the cord, and turned it over to some attendant to be bathed and clothed.
He almost forgets the little stranger unless someone calls his attention to
something that they consider abnormal. The baby should be watched as care-
fully as the mother, yet usually she receives most of his attention. He should
give detailed instructions as to the care and nursing, and then follow up and
see that these instructions are carried out.
Dr. L. W. Elias, Asheville: This is a very interesting paper, and
brings up a good many things to think about I wonder if the doctor thinks
that opening up those abscesses had anything to do with the rapid increase in
temperature. I wonder if he thinks an aspiration would have had any less
effect.
Certainly, the doctor's suggestion in regard to the care of the baby should
be most heartily commended.
Dr. Yates W. Faison, closing the discussion : That question was con-
sidered, and the surgeon overruled us and decided to open up freely and
drain. It was considered. The point has been brought up in discussion about
this case before that probably opening these abscesses and letting them drain
gave the child resistance enough to cause the temperature. It did not go
down and then come up again.
SIMPLIFIED INFANT FEEDING AND THE BREAST
A RATIONAL FEEDING PROGRAM FOR THE FIRST YEAR
OF LIFE
Frank Howard Richardson, M. D.
Assistant Pediatrist, and Chief of Children's Clinic
Brooklyn Hospital, Brooklyn, N. Y.
Read before the Pediatric Section of the Medical Society of the State of
North Carolina, at the Sixty-Seventh Annual Meeting, held
at Charlotte, N. C, April 21, 1920.
Infant feeding, whether simplified or complicated, as a subject for discus-
sion before a Pediatric Section, is something to be approached with caution.
PEDIATRICS 187
The changes have been rung upon it so often and in so many different keys,
that one feels like treading lightly and asking for a special dispensation for
discussing it. And yet I think that no one will deny that Infant Feeding
needs simplifying, if there is any subject within the whole broad scope of
modern Medicine that does. There are perhaps a number of reasons for
this. First, Pediatrics, along with a number of other subjects in the medical
curriculum that are of greater age as recognized specialists, is considered a
minor in our medical schools, and is crowded out of the students' time and
interest by other supposedly more important subjects. And yet Pediatrics
is the only branch of the whole array that deals with the well organisms
and the only specialty that must be practiced by every general practitioner.
Secondly; As a result of this comparison of a large and important subject
into such small compass, the professor and instructors are inclined to em-
phasize the striking cases, of a sort less commonly encountered, rather than
to dwell upon those far commoner and hence (to them) less interesting
problems of everyday occurrences, and especially these concerned with in-
fant feeding.
Thirdly: The subject of Infant Feeding itself is one that has given rise
to most acrimonious debate, due to honest divergence of opinion on the part
of widely differing schools of thought.
Fourthly: This difference of opinion as to what constitutes a satisfactory
system for the feeding of infants has been able to persist as it has, because of
the relatively wide limits of tolerance possessed by different infants, and by
the same infant at different times, for the most widely differing articles of
diet. We have each of us but to consult his very recent memory, in order
to recall some perfect specimen of babyhood, that has arrived at this condi-
tion on feeding that we would have said must surely have led to speedy
marasmus — explicable on no other grounds than those of the tremendously
wide limits of food tolerance possessed by some babies.
Fifthly: The fact that such widely differing schools of thought could
each of them point to a highly satisfying and successful series of cases, has
led each group to believe that it had fairly well solved the problem of infant
feeding. It has also caused each group to doubt the possibility of attaining
the equally successful series of cases claimed by the proponents of some
entirely different set of principles. All have perhaps failed to put proper em-
phasis upon the fact that a great body of babies, fed according to any old
methods or to no methods at all, were worrying along perhaps almost as
well as some of these special series had been doing. They had been studying
especially the sick baby, with his greatly narrowed limits of food tolerance
due to the food injury that he had sustained; and had failed to attempt to
formulate, from the experiences of this large mass of carelessly fed but fair-
ly healthy, well babies, a simple method that could be readily taught the
average student, graduate or undergraduate, and by him passed on to the
average mother or nurse. In other words, the student has been taught a
complicated method of feeding, desirable enough perhaps in special cases of
food injury, but by no means essential for the great mass of well babies. Ac-
cordingly, he has been well-nigh helpless, in the face of the demand of his
mother's instructions for the feeding of their well children, because he has
never been taught a simple system which simple folk, with a well baby, will
take the time and trouble to follow out.
188 NORTH CAROLINA MEDICAL SOCIETY
The result of this lack of a definite routine procedure for use in the case
of the average well child, such as can readily be taught to and learned by
the average medical student, and by him translated into simple instruction*
for the average mother or nurse to carry out from day to day, can be seen
all about us. We know that many otherwise able and conscientious physi-
cians never attempt to interfere in the management of the well babies of
their families. They regularly allow some elderly female of the species to
prove herself more deadly than the medical male, by using her experiences
of a generation ago to decide proportions, dilutions, quantities, and feeding
intervals, — after first using her superior judgment for instructing the young
mother when to take her baby off the breast. Others, when appealed to, turn
with a sigh of relief, to the proprietary foods, which never fail to promise
most flattering results, — and every so often, let us be frank enough to ad-
mit, achieve them. Many babies, we know, with the broad limits of toler-
ance that we have spoken of, survive this catch-as-catch-can process. Many
more succumb, to swell the frightful mortality figures that we have come
to feel are unavoidable with artificially fed infants.
While granting that we must individualize, even with our well babies,
just as we individualize with our typhoids or with our appendectomies, it
must be that we can standardize and teach infant feeding, just as we stand-
ardize and teach typhoid therapy and surgical technique. It seems not
too much to ask that the outlining of general principles should precede
rules for specialization to meet individual conditions.
I have been brought to believe, from a brief survey of my own brief ex-
perience, that a large proportion of the cases that are referred, or drift, to
the man doing pediatrics exclusively, whether in private practice or in hospi-
tal work, are feeding cases that could have been handled perfectly well by
the family physician. He has failed, from the lack of a definite technique to
apply, in his infant feeding cases, similar to the routine procedures which
he is wont to apply in other situations. In other words, the pediatrist is
achieving much of his reputation as the result of his successes with easy
feeding cases, instead of being compelled as he should be to tax his best skill
and ingenuity over the difficult ones alone. If this be true, then there is a
serious flaw somewhere in the program of medical education today. For the
future welfare of the race is in the hands, not of the pediatrist, who, in the
very nature of the case, sees comparatively few of the whole infant popula-
tion ; but of the family doctor, who, sooner or later, sees the vast majority
of them at least once in their lives. But it is to the pediatrist that the fami-
ly practitioner, when in the embryo stage represented by the medical student,
looks for his instruction in this most important matter. If we fail him (and
my memorv of the instruction given me during my undergraduate years
leads me to think that we are failing him), can we blame him when he al-
lows that more plausible teacher, the detail man from the proprietary food
concern, to usurp the seat in the teaching chair that has been so inadequately
filled? And yet, hand in hand with this admitted unfamilarity with the
intricacies of infant feeding, on the part of the great majority of the medi-
cal profession, goes a most amazing readiness to wean babies for the most
trivial and inadequate of reasons. When one has struggled as desperately
as every man in this section has done, many a time and oft, over the artifi-
cial ailmentation of a puzzling case, one is simply awe-struck at the sang-
PEDIATRICS 189
froid with which babies are taken off the breast, every day, for acuses so
trifling as to be laughable, were not the results apt to be so serious and even
tragic. "The baby doesn't get enough milk." "I never have been able to
nurse my babies-" "My milk is blue and watery — I know it doesn't nourish
the baby." "My baby didn't gain this week." "My milk poisons the baby"
or any one of a dozen other such statements, that should mean nothing more
radical than an inquiry by the physician into the state of nursing affairs, and
some simple adjustment or explanation, ushers in the change from nature's
feeding, which works so well that no one needs to understand it, to bottle-
feeding, which is admittedly but the poorest of substitutes, and is but
wretchedly understood by the best. As often as not it is the grandmother,
the aunt, or the nurse, who blithely crosses this Rubicon, with never a qualm
over future hazards, and never a regret over bridges burned behind. One
can hardly imagine a shipwrecked sailor's pushing away his life-preserver,
or a mountain climbers tossing away his hobnailed boots ; and yet either of
these would be taking a far less serious risk than is thus imposed upon the
infant whose breast alimentation is thus discontinued for these absolutely
inadequate and avoidable reasons.
The first step that I would urge in the simplifying of Infant Feeding,
then, would consist in keeping every baby on the breast. I grant you at
once that such a dictum as this, solemnly enunciated without further ampli-
fication, would constitute an insult to your intelligence, and an admission of
my ignorance of the state of medical knowledge today. I should not have
the effrontery to urge upon any body of physicians, — much less upon a group
of men engaged as you are wholly with the problems of infancy and child-
hood, — the already universally acknowledged superiority of breast feeding
over the best of artificial feeding. This has been so generally conceded, and
the literature has been piled so high with reports, experiences, statistics, and
conclusions, to this effect, that it would be a waste of time to try to find any-
one who would oppose what has come to be considered almost an axiom of
pediatrics practice. What I do want to stress today, however, is the dispari-
ty existing between our theory and our practice, in this regard. What I do
want to plead for today, is the realization, first upon the part of the indi-
vidual practitioner and through him upon the individual mother, that what
both know and concede to be true in the great mass of cases, is in all proba-
bility true in the individual case that they are considering, and whose wean-
ing they are proposing. No one ever claims that bottle feeding in the ab-
stract is better than breast feeding. It is only when we urge a mother to
keep her own baby on the breast, even at the expense of some pains and
effort on her part and ours, that we meet with any opposition to the con-
tinuance of breast feeding. And we certainly do meet with it; then, as
everyone of you will, I know testify with me.
I personally am firmly convinced of what is by no means universally con-
ceded or recognized, — namely, that practically every mother can succeed in
nursing her own child. I say "practically" advisedly, in the face of the testi-
mony of the textbooks, which are fond of citing cases of congenital or ac-
quired intolerance on the part of certain infants toward its mother's milk.
I am willing to go a step farther, and concede that probably each man here
can call to mind one or more cases in his own experience in which every
effort to keep a baby on its mother's milk failed ignominiously. And yet, to
190 NORTH CAROLINA MEDICAL SOCIETY
Strike a quick percentage, what tiny fraction of a percent is represented in
the practice of any one who recalls such a case or two of so called toxicity
as compared with the total number of babies he has seen. We have all of
us heard or read of the existence of two-headed calves ; and yet we do not
ordinarily construct our stanchions so as to accommodate these rare freaks
of nature.
Mind, I do not claim that every mother, or anywhere near every mother,
can carry her baby through the nine months that we set aside for lactation,
without help. But I do say that, given a realization on the part of the
mother and of her medical attendant of the truth in her particular case of
what both recognize to be true in the vast majority of cases, — and every man
who wishes it can reduce his panel of exclusively bottle-fed babies almost
to the irreducible minimum supplied by motherless babies, and babies that
have been weaned three or four weeks before he sees them. And, if we are
to credit the results of Moore, of Portland, Oregon, as set forth in his fas-
cinating paper in the Archives of Pediatrics for December of last year, even
this minimum may prove not to be an irreducible one, after all, for he re-
cords one case of re-establishment of breast feeding after 8 weeks of wean-
ing, and another after 11.
Granted, then, that mother and physician are in accord and resolved to
do their best to keep the baby on the breast. What can we do to help them ?
In view of the universally admitted superiority of breast feeding, it is rather
surprising that we can find so little, relatively speaking, of real practical
help, in the text-books or in the literature, to aid us in this task. The task
is a two-fold one ; first, the maintenance of lactation, and secondly, the ad-
justment of the milk to the baby or of the baby to the milk. In comparison
with the volumes and reams devoted to the intricacies of artificial feeding,
the space given to the problems connected with the far commoner class of
breast feeding, seems almost negligible. I want to outline the regimen that
has been found most successful here, emphasizing with it details which are
perhaps the most important feature in the management. In a word, this
consists in the inauguration of what is variously known as auxiliary, com-
plementary, or supplementary feeding.
By whatever name we call it, let it be distinctly understood that what is
meant is ofFering the baby a bottle, with a formula appropriate to its age,
weight, and general condition, after every breast feeding^ and letting him
take as much or as little of it as he will. What is not meant is alternate
breast and bottle feeding ; for reasons that will be dealt with in a moment.
He may be kept anywhere from five to thirty (or in rare instances more)
minutes on the breast; until he shows, in short, by his restlessness and the
tossing about of his head, that he has about exhausted the possibilities of the
one breast. He is then allowed to swing over to the bottle, previously heated
and in readiness, and permitted to take as much as he will of the comple-
mentary feeding. It is probably well within the bounds of truth to say,
(grandmothers to the contrary nothwithstanding) that a reasonably well
baby never overeats, if given a food of the proper strength. "Colic," so-
called, from this cause, can far more often than is realized, be proved to be
nothing but hunger, by allowing the child to take even more of the food
than he has already taken. Even that infallible argument, "Why, doctor,
I know it's colic; he just draws his little legs up on his stomach when he
PEDIATRICS 191
cries," will_ fail of effect, when the mother sees the "colicky" baby fall
asleep just as soon as he is allowed to be the judge of his own capacity. In
other words we are quite safe in allowing the baby in this way to tell us
how much too little breast milk he is getting.
The following ideas should gradually be inculcated in the mind of the
mother. It is especially useful, in this connection, to give a small slip or
folder, preferably typed or printed in simple language, embodying these
points:
1. That she should get away from the baby at least once in the twenty-
four hours, — for the sake of both individuals.
2. That she should get enough sleep ; eight hours representing a mini-
mum rather than a maximum.
3. That worry is a great milk reducer. If the doctor can keep up the
baby's weight and satisfy his appetite with complementary feeding, and give
the mother confident assurance of ultimate success he can generally obviate
the untoward influence of worry.
4. That she may eat whatever she pleases, within ordinary bounds of
reason, provided it does not cause indigestion on her part. The baby will
not be affected by what she eats.
5. That excessive amounts of milk, cocoa, beer, or even water, do not
necessarily, or even usually, aid in improving either the quality or the quanti-
ty of milk produced. That such excesses, on the contrary, usually in the end
do harm, by spoiling the good appetite so necessary to lactation, if not ac-
tually upsetting the digestion.
6. That, in general terms, the same regimen that produces health and
strength and bodily well-being, produces milk.
7. That no special diet can greatly modify the chemical constituents of
the milk. The best opinion today is emphatically agreed on this. Further,
some authorities believe that quantity alone can be altered, — that the quality
is, in an overwhelming majority of cases, always good.
8. That a laboratory test of the character of the milk is never of any
practical use. The only test that is worth while is the practical test as to
its efifect on the baby. If he is hungry, or is failing to gain, he should have
complementary feedings until the breast supply becomes adequate, as shown
by these two criteria.
9. That the milk never disappears suddenly, beyond recall, — say within
twenty-four or forty-eight hours. Such an apparent vanishing of lactation
is always evanescent, if complementary feeding is instituted promptly. The
temporary diminution of the milk secretion can in this way always be made
up for, the baby be tided over, and an enforced weaning be done away with.
10. That the care of the nipples is a most important phase of the periods
of later gestation and lactation. It should begin a month or two before the
birth of the baby, in the case of a mother who has depressed nipples. Gentle
manipulation for a few minutes daily will make these easy for the baby to
manage. Cleanliness, hardening by the application of one-half strength
alcohol, and protection by the employment of inch-square bits of sterile
waxed paper, are important aids in keeping the nipples fit. Bismuth and
caster oil, equal parts, may be used for incipient cracking. Many women
192 ^ NORTH CAROLINA MEDICAL SOCIETY
find that their nipples will not stand the wear and tear incident to nursing
a child on both breasts at each feeding. Nursing on alternate breasts is usu-
ally advisable. However, as early milk is thin and watery, as compared
with later milk, which is richer, or strippings, which are very high in fat,
we may 'if we wish diminish the fat content of what we are offering the
baby by allowing him a shorter period at each of the two breasts at one
feeding. As he fails thus to empty the breasts completely, however, we must
be on the lookout, in such cases, for a reduction in the milk supply,
11. That we know of but two galactagogues. One is the stimulation of
the infant suckling at the nipple. The other is the complete emptying of the
breast at each nursing. These can be temporarily stimulated; the first, by
the breast pump and nipple massage, the second, by the breast pump and
manual stripping of the breast, preferably after the manner described by
Moore of Portland in the December Archives of Pediatrics. But the best
agency of all is the one that combines the two, — namely, the nursing baby.
12. That milk is like the manna that the Lord provided for the children
of Israel, — it cannot be stored up in the breast nor saved there for future
use. A thorough understanding of this act will do away with that bane of
the doctor who is trying to improve a breast supply, — namely, the alternate
feeding of breast and bottle, (supplementary feeding proper). This is very
frequently indulged in on the mistaken supposition on the part of the mother
or her friends that there is not enough milk for all the feedings, and that
in this way it can be eked out. Lacteal glands, like muscle tissue, work the
better the more they are called upon to perform, within physiological limits.
The surest way in which to dry up a breast supply, is thus to skip several
feedings a day.
There seems to be no reasonable doubt that a moderate amount of breast
milk does "take the curse off" the bottle feeding. Whether it be a question
of carrying over antibodies from the mother to the baby, or whether it be a
question of vitamines, or whatever the cause may be, we know that the child
on complementary feedings shares much of the good fortune of the entirely
breast fed infant. Then too, after weeks, or perhaps even months, the
breast may begin to function to such an extent as to render further artificial
feeding unnecessary, either temporarily or until weaning time. Such a solu-
tion as this, of a feeding problem, never offers itself unasked, in the case of
the entirely bottle fed baby!
A fair degree of familiarity on the part of the attending physician with
some comparatively simple form of infant feeding procedure to employ for
his complementary feeding, is of course, necessary. Surely, however, this is
not too much to ask of any man who is dealing as extensively with women
and children, as is the general practitioner.
And so, back we come, or around we come, after all, to the favorite topic
of pediatricians, Infant Feeding. The practitioners (and they are not few)
who refuse to admit that there is such a speciality as pediatrics, taunt us
with the gibe that every pediatric meeting, whatever its announced topic,
either starts out or ends up with a fuse over infant feeding. If a personal
experience is allowable, I must confess that after some years in hospital and
clinic work with children, it was still with fear and trembling that I ap-
proached an ordinary feeding case ; and it was still a good deal a matter of
PEDIATRICS 193
chance what feeding mixture such a new case would receive at my hands.
I felt convinced that the old, complicated methods on which pediatrically
speaking, I had been brought up, were somehow wrong; and yet I did not
know what was right. My feeling of dissatisfaction with the old stuff may
perhaps best be expressed by an illustration from life. If the operation of a
trolley car were such a delicate, complicated matter that no one but an Edi-
son could compass it ; and you needed fifty trolley cars to handle the traffic
of your city; then you will agree with me that the trolley car, as a means of
handling your traction needs, would fail as a working, practical proposition.
For there are not available Edisons enough to go round. Similarly, if it
takes a Holt, a Morse, or a Kerley, to feed j^our baby and mine, Mrs. Jones's
and jVlrs Brown's, then infant feeding, as taught today in the east at least,
is a failure. But we know that it is by no means as rare an occurrence as
we could wish, to have a mother bring back to us, after two or three months'
absence, a big fat baby that we have failed to make gain on the most scienti-
fic formulae, with the triumphant remark, "Oh, Doctor, see what Blank's
Food did for my baby." Not pleasant, is it? Nor yet, as sometimes has
happened to the best of us, to have Grandma's mixtures preferred by an
ungrateful child to our elaborate formulae. Such occurrences compel seri-
ous consideration.
Some time ago my attention was called to what was to me an interesting
attempt to join in the holy bonds of matrimony two systems hitherto con-
sidered hopelessly unmarriageable, — namely, the percentage and the caloric
ideas of infant feeding. I believe that Dennett, in his book Infant Feeding
and even more in the teaching in his Seminary at the New York Post Grad-
uate Hospital, has done more than anyone else in the east to popularize this
union in a workable technique. In every marriage, each party to the contract
•contributes elements that the other lacks, to make up a complete unit. In
this marriage of the percentage with the caloric, — of the east with the west,
— of the Bostonese with Chicagoese, if yau can conceive of such a union be-
tween such incompatibles — we shall rely upon the so called percentage
method to tell us zvhat to give the baby; and upon the so called caloric
theory, or method, to tell us how ?nuch to give. But, in order to fulfill the
requirements that vi^e set for ourselves in naming this investigation, we must
produce something that is really simplified, — it must be, not a head-splitting
arithmetical jumble of proteins, carbohydrates, fats, and calories, but a sim-
ple, straightforward rule-of-thumb working svstem, — simple enough to be
workable for him who runs to read and to apply.
The part in our scheme that the percentage method is to play, then is to
determine how best to make our mixture digestible, — a matter that the
caloric method, so called, never attempted to help us with. This simple
point Chapin, for instance, absolutely disregards, in his diatribes against
calories, in which he attempts to reduce the whole idea to the ridiculous by
suggesting that we furnish the necessary calories to the youngest in the form
of coal oil.
Without getting ourselves into the usual arithmetical tangle by comparing
the percentages of the three food elements in human milk and in cows milk,
let us recognize that there are three elements, any one of which may under
certain conditions give us trouble in adapting the milk of the cow to the
194 NORTH CAROLINA MEDICAL SOCIETY
Stomach of the human, — namely, fat, sugar, and protein; disregarding the
salts, about which we know as yet so painfully little. Let us dispose of the
danger due to the fat, by reducing it to a very low amount, — which will be
the case if we dilute ordinary cow's milk with twice as much water; i. e.,
give one-third milk and two-thirds water. This same process will reduce
the harmful potentialities of the sugar to an even greater degree by reduc-
ing it so far that we shall have later actually to add some sugar to our mix-
ture in order to have enough to approximate it to the human norm. The
protein can be disposed of even more simply, — by subjecting the diluted milk
to a boiling process for three minutes, which completely breaks up the curd
when acted upon by the stomach juices, as has been conclusively demonstrat-
ed by Brenneman of Chicago in his classic work on boiling milk. That the
protein of the milk is "the cause of many of the nutritional disorders en-
countered in infancy" is categorically denied by Grulee, of Chicago, in his
"Infant Feeding," (page 167 sec. — . ) He is sure that the so called "case
in curds" are irritant only mechanically; and that this source of trouble is
eliminated by boiling. The only possible objection to this, that it may cause
scurvy in time, is done away with absolutely by the feeding of orange juice.
If, then, we agree to start any child that comes to us on a mixture of one
part cow's milk and two parts water, boiled together for three minutes,
with no sugar added, we shall at least be giving a mixture that can do him
no harm. For our fat is diluted far below that in human milk, our sugar
is almost absent, and our casein, the protein constituent, has- been rendered
harmless by boiling, so that it will form a finely divided curd when it meets
with the digestive juices of the infant's stomach. Any possible ill effect of
the boiled milk we shall eliminate by feeding him a little orange juice once
or twice a day. But this, if we start with 10 ounces of milk and 20 of water,
will probably be insufficient. We can prove this by multiplying 10, the
number of ounces of milk by 20, the number of calories in an ounce of milk,
— the water, of course, having no caloric value. That is, our initial formula
which we agree is digestible, is worth 200 digestible calories, if you will.
While it is much better, by all o'dds, to give too little of a digestible food
than to give any amount of an indigestible one, still we must eventually
come up to his digestive requirements, best measured in calories, if we are
to look for a gain. But how are we to ascertain what this caloric need is?
By multiplying the number of pounds the baby weighs, say 10 pounds, by
50, which is an average calculation of the requirements of the average child
per pound per day, we shall arrive at the number of calories that we must
eventually give our baby in assimilable form, if we are to get him to thrive
and gain weight ; in this case, 500. Starting, then, with our trial or initial
formula of 10 ounces milk and 20 ounces water, we may gradually strength
en this until we have brought it up to the number of calories (in this case,
500) that we have determined upon as a normal daily feeding for our baby,
■eventually. Our strengthening must be in terms of two factors only, how-
■ever; namely, milk (with its 20 calories to the ounce) and sugar, (with its
30 calories to the level tablespoonful). 5 level tablespoonfuls, or 150 cal-
ories, may be taken more or less arbitrarily as the total sugar content at
which to aim. It is probably better borne in the form of dextri-maltose than
in that of either cane sugar or milk sugar. In order to decide how many
ounces of milk we shall eventually want to give our baby, we may subtract
PEDIATRICS 195
150, the number of calories to be contributed b_v our five level tablespoon-
fuls of sugar, from the total number of calories previously determined upon
(by multiplying the number of pounds the baby weighs, by 50, his daily re-
quirement per pound.) This total, divided by 20, (the number of calories
in each ounce of milk), gives the amount of milk needed.
This leaves us nothing to determine, but the amount of water to be used
in the final total feeding. In order to do this, we shall simply have to de-
termine the total bulk to be given the baby in the course of the day, which
will be the number of bottles to be given, times the number of ounces in each
bottle, determined by any rule that you have been using in the past. A gen-
eral average might be represented by 7 feedings (which gives bottles enough
for a feeding every three hours during the day, and one night feeding) times
3, 4, 5, 6, or 7, the number of ounces per bottle, according to the age of the
child. This bulk must be furnished by the water plus the milk, as the sugar
goes into solution. As the number of ounces of milk required has previously
been determined, we need only add water to bring up the total to the total
bulk desired.
Now we need not, nay must not, aspire to reach this desired haven of the
optimum number of calories at a bound. Grant that our baby may, and
probably will, be hungry, long before we have advanced him from the — 10
oz. milk — 20 oz. water — on which we started him, to the optimum formula
that we have decided he must ultimately reach. But we are, all of us, com-
mitted to the principle of making haste slowly, in feeding babies ; and at
least we do away with the formerly commonly accepted 24-hour starvation
period. The hungry baby worries the mother with his crying ; but the child
that worries the doctor is the baby that has no appetite.
Leaving all theory aside, the practice is this. Start virtually every baby
on a mixture of 10 ounces milk and 20 ounces water, boiled together for
three minutes, with no sugar added. The caloric value of this is 10x20, or
200. Experience will tell you when it is safe and advisable either to give a
stronger mixture or a greater bulk at the start, for this trial formula, as we
may call it. With this weak strength and small amount, the preliminary
starvation period that we used all to insist upon has been found quite un-
necessary and hence a loss of valuable time, in most straight feeding cases.
Add an ounce of milk a day. The caloric value increases thus 20 a day.
Add a level^tablespoonful of sugar (preferably in the form of a malt sugar),
every few days, in place of the increase in the milk, computing the value of
the food on those days by adding thirty calories for each level tablespoonful
of sugar added, instead of the twenty that would have been added by the ad-
dition of an ounce of milk. 5 level tablespoons make a good average quanti-
ty. In order to determine whether water should be increased, left as it is,
or decreased, we must know how much bulk we want our baby to have in
the twenty-four hours. This is easily arrived at, by multiplying the num-
ber of feedings (say 6 or 7) by the number of ounces he is to get at each
feeding (which averages an ounce per month, — more in the early months,
of course, and less in the later.) The difference between this total, and the
number of ounces of milk, will represent the amount of water needed. — as
the sugar, of course, dissolves, and so occupies no bulk. Before long, add the
juice of half an orange to each day's dietary.
196 NORTH CAROLINA MEDICAL SOCIETY
The question of the best interval at which to feed is a point which is
variously settled by different schools. My own custom has been largely the
result of the method described by the homely phrase "cut and try." The
two-hour interval I use only in the case of prematures; and the two-and-a-
half, only as a step or half-way step in the course of changing from the two-
hour interval on which a baby may be when he comes in, to the three-hour
interval at which I always prefer to start. As soon as the baby is doing per-
fectly well on this, — by which we understand that he is being fed at 6 a. m.,
9 a.m., 1 a.m. and 3, 6 and 10 p.m., and once during the night, — and seems
satisfied to wait from one feeding to another, and occasionally sleeps
till well along toward morning, I advise the mother to dispense with the
night feeding, by giving first water when the baby wakes and cries and then
omitting both nursing and water. This is the routine for babies that are not
seen at birth ; those cases that are, do not have any night feeding at all, be-
ing given warm water at two o'clock a. m. or later if they wake, which they
soon cease to do. As early as the end of the first month, I suggest to the
mother that she will probably find it easier for both the baby and herself if
she can change over to the four-hour interval. If the idea appeals to her, I
have her allow the baby to go as long as he will from feeding to feeding, —
three and a half hours if he will not go four, — for about a week. Before
the end of that time, a well-fed baby is usually established on the four-hour
schedule. The same free and easy method is used at three or four months,
if the baby is satisfied and the mother cares to try, with regard to omitting
the 10 p. m. feeding. These changes are so much easier for the mother, and
involve so much less handling of the baby, that they are usually easy to per-
suade the mother to try for. It is hardly worth insisting upon, however,
and especially is contra-indicated if the baby is hungry, and ready for the
bottle at the end of the three hour interval. The baby's own hungry inclina-
tions can here be safely relied on and show us his needs if we will study him
carefully.
A most valuable adjunct to employ at times in the management of difficult
cases is that much talked of agent, dry milk. Like most other proprietary
preparations, it has its very definite dangers in its likelihood to become a very
intolerant master, as soon as it gains in the minds of the laity the place that
we are apt carelessly to help it to attain. In the child who has suffered a
"food injury," it is often a most valuable aid, with the lowered fat content
that at least one brand offers, and the apparently increased adaptability con-
ferred by the heating process. Especially if one had reason to doubt either
the intelligence or the zeal of the one who is to prepare the complementary
food, is this an efficient and valuable ally. If caloric value is given as 16
calories to the level tablespoonful (leveled, that is, with a knife).
A word as to the management of prematures, in order to cover the various
phases of the feeding of the first year of life. It is coming more and more
to be realized that it is a waste of time, — nay, of human life, — even to at-
tempt the feeding of the premature infant with anything other than human
breast milk, either whole or diluted. Strengths and intervals may well be
left to the individual feeding the individual case. I am firmly persuaded
that the obtaining of the tiny amount of breast milk needed for the first days
and weeks of the life of the premature, is by no means the difficult or im-
possible matter that we are apt, offhand, to consider it. That community
PEDIATRICS 197
must be a tiny one, indeed, in which there is at any one time but one nursing
baby. And it should be most rare, indeed, to fail to find a mother who, if
the need were fully and carefully explained to her, would be glad to spare
for the starving baby of her neighbor the few drops necessary to save its life,
from the bounteous table that nature has set for her own more fortunate
child. In the larger community it is easier; in the hospital, comparatively
simple. Cooperation between the obstetricians and the pediatricians has in
more than one instance resulted in the establishment of some central agency,
at which the parents of the infants whose need for human milk is urgent,
can be put in touch with the mother who is willing to supply, on a financial
basis, a stated amount of breast milk per day. A more interesting bit of
hospital wire pulling has been the feeding of the premature, by means of a
pipette or Breck feeder, on a diluted breast milk expressed from a mother
in the maternity ward, while the supply of its own mother was started by
placing to her breast a needy baby from the pediatric ward, who greatly
benefits by the operation, until the premature can get his supply direct by
nursing at his own mother's breast.
Weaning is a procedure which entails no suffering on the part either of
mother or of child, since the brutal old custom of abrupt weaning was done
away with. At about the sixth month, or thereabout, the mother is told to
precede each breast feeding with a tablespoonful or two of a cereal. As
soon thereafter as one wishes, the vegetables may be added, one by one, as
baked potato with milk, spinach, carrots, mashed peas and beans. As these
additional articles are judiciously used to expand the baby's dietary, he will
naturally become less and less dependent upon the breast milk, which, to-
ward the end of the nursing period, he will be using more as a drink than
as a sole dependence for nourishment. Milk, either diluted, and without
sugar, or straight, may be added as desired. In this way, the change from
breast feeding to general diet is made so gradually as to be almost impercep-
tible. It is only fair, in this connection, to mention the paper in which
Morse, of Boston, sums up very fairly his objections to this procedure, and
his reasons for adhering more strictly to the older custom of introducing
these articles of diet considerably later. The change can be made quite as
gradually from the four hour feeding intervals to the more conventional
hours of meal times. The 6 o'clock feeding becomes a 7 o'clock breakfast
with cereal (without sugar), milk, orange juice, and bread. The 10 o'clock
feeding becomes the pre-nap lunch of crackers and milk. The two o'clock
feeding is easily recognized in the after-nap dinner, with the addition of
baked potato and milk, one other vegetabl, bread or toast or zwieback, and
a simple pudding. The six o'clock feeding is less deeply camouflaged, ap-
pearing as supper, with Graham or Wheatsworth crackers and milk, and
stewed fruit. The omission of eggs in any form, and of the elaborately pre-
pared beef broth or scraped beef, is intentional. The value of the former
is more than problematical ; the labor^ spent on the latter is out of all pro-
portion to its value, which has undoubtedly been greatly exaggerated.
SUMMARY
Infant Feeding, as taught until yesterday in the schools, needs simplifying
and needs it acutely.
2. The first step in simplifying, and the most important for the welfare
198 NORTH CAROLINA MEDICAL SOCIETY
of the race tomorrow, is the maintenance of breast feeding, partial or com-
plete, in the vast majority of our babies,
3. Such a statement alone is inadequate. Proof of the assertion, as well
as help to the mother in accomplishing it, are needed. This consists in the
"adjustment," as I like to call it, of the breast to the baby, or the baby to
the breast.
4. I have attempted to show how any man may keep that wonderful
ally, old Gradma Nature, on his side, — and in many cases, take all the
credit while he allows her to do most or all of the work.
5. To do this, requires a reasonable familiarity with some reasonably
simple form of Infant Feeding procedure, for use in connection with the
breast feeding, at some time during the period of lactation. I have tried to
formulate the simplest that I have yet found.
6. A useful servant, but one that must be watched lest he assume the
mastership, is some form of dry milk.
7. The successful care of any respectable proportion of prematures pre-
supposes the employment of breast milk in all cases.
8. Breast milk is not the rare thing we like to consider it, — we can get
it for the premature, if we go after it hard enough.
9. Weaning is a gradual affair, — as such it may be accomplished abso-
lutely without disagreeable effect upon either mother or child, if it be be-
gun early enough.
1 0. References.
Ladies and Gentlemen, I have tried to give you my articles of faith with
regard to the management of the feeding of the ordinary baby — or one that
approximates the ordinary. (For no mother will ever admit that her baby
could be classed as ordinary, by the dullest imagination). Endless variations
from the average may be made, to suit the individual baby, and to increase
its flexibility in the hands of the individual infant feeder. A necessary part
of the technique, in actual practice, that I have not attempted to bring
out, consists in the rendering of frequent reports and the maintaining of
constant touch between mother and doctor. This is absolutely essential, for
checking up results, to see if directions are being carried out, and to detect
and correct errors arising from a misunderstanding of directions. (In my
own case, this is covered by the morning telephone consultation hour, at
which time mothers are encouraged to telephone in reports and questions,
with absolute freedom.)
Some such skeleton technique, flexibly and humanly applied, that may
easily be taught to any man who has to deal with babies, will carry perhaps
95% of our babies safely through the first, or critical year of life. If this
is true, and I believe that a large number of men might easily be found
whose experience will confirm it, we may reasonably leave the remaining
5% or less to be discussed in some more highly technical treatise than 1 have
attempted here.
REFERENCES
1. C. Ulysses Moore, Arch. Pediatrics, Jan-, 1920.
2. Roger H. Dennett, Simplified Infant Feeding
PEDIATRICS 199
3. Chapin, H. D., Do Calories Measure the Value of Food? J. A. M.
A., 27 Dec, 1919, v. 73, No. 26.
4. Brenneman. Am. J. Dis. Ch., 1911 I 341.
5. Ibrahim. Monatschrift f. Kinderheilkunde, 1911, x 55.
6. Grulee. Infant Feeding.
7. Holt and Howland. Diseases of Childhood, 1918.
8. Hill and Gerstley. Clinical Lectures on Infant Feeding.
9. Rubner, M., and Heubner, O. Die Naturliche Ernahrung eines
Sauglinges. Zettscrift f. Biologie, 1898, neue Folge XVIII, pp. 1-55.
(First ref. in lit. to Cal Fdg of Inf.)
10. Hill, Lewis Webb. Review of Methods of Infant Feeding. Bost
on Med. Jour., April, 1920.
11. Talbot, Fritz. Arch. Fed., 1910, XXVII, 440.
12. Morse, Robert Levett. Jama, 28 Feb., v. 74, No. 9.
13. Love, J. D., J. A. M. A., 19 Dec, 1919, (Abstract.)
SIMPLIFIED INFANT FEEDING.
Dr. Frank Howard Richardson, Brooklyn^ N. Y.
EXHIBIT NO. 40.
Dr. J. R. Ashe: We have all enjoyed this very instructive paper of Dr.
Richardson's. I find that a great many mothers who are feeding infants
need help. Most of these mothers, if we do supplement their feeding they
are perfectly able to nurse a baby for several months.
I find so many babies four and five months old, whose mother's milk is
just beginning to fail, you can't make it take the bottle. She does get a
little in its mouth by the spoon. I have had so many to act that way. I
have made it a rule to try to start the babies out on bottles when two or
three months old, whether they need it or not.
Dr. B. L. Smith : My only rule in feeding babies is the time. Laying
aside the quantity etc., the only rule I insist, if a child takes his food at six
in the morning I want him to take it at 6 the next morning, etc. The most
important part of feeding is fixing the food to suit the baby. I have been
using in the past two years the dried milk as supplementary food to the
breast. I found that the most easily prepared — one advantage it has over
the condensed milk is that the child will not wean itself from the breast on
account of the sweetness of the milk. I do not feed it as a food, except as
supplementary food, or in emergency cases.
Dr. Richardson's paper was hard to discuss, but you can bring out a few
things. I always give the bottle after the breast. I found that if you put
the babies on water that that is sufficient to keep them up with the bottle,
and they will at anytime adopt the bottle of milk in place of the breast, that
is if you have them acquainted with the bottle.
L. T. RoYSTER, Norfolk, Va. : I have very little to say. I have never
taken a baby of^ of mother's breast because the milk did not agree with it.
I have not seen a case like that yet. Anyone that attempts to take babies off
of the breast because it has colic, had better stick to the ills we have and not
200 NORTH CAROLINA MEDICAL SOCIETY
rush to others. I have never taken a baby off of mother's breast and I see no
reason for it at all. The use of the terms complementary and supplement-
ary are rather confusing, some use supplementary as adding to the mother's
feeding. I always use supplementary, if I can possibly do so feeling that one
dram of mother's milk at each nursing is far better than no dram.
The other principle is, if we alternate the feeding, the mother's milk will
dry up very quickly. The breast pump is the last thing on earth to use.
The nurse can be taught to nurse the mothers, as well as the milkman to
milk the cow. I never use a breast pump if I can avoid it. The mothers
can nurse the milk out of their breast if taught by the nurses. A baby sud-
denly weaned from a mother's breast by the death or illness of the mother,
if it is a healthy baby it should present practically no difficult in feeding. We
must know what takes place in the stomach or intestines. I was fortunate
enough to study in New York, and in those days we had to figure down to
the minutest percentage. That day has passed. Now we realize that any
of those foods may cause indigestion. I will say that that is very frequently
the case — fats and sugar — whether mixed with milk or not and where the
rules are laid down by the manufacturer — unfortunately too many of us let
the manufacturer be our teachers. Personally I never used any of the dry
preparations. I do use mixture of Dextrine and Maltrose, but it is too lax-
ative, and therefore we have not gotten to that point. If we start any child
that is healthy on milk formula, disregard its weight for ten days or two
weeks to be sure we have not any symptoms of indigestion. I have never
used a dram of condensed milk in my whole 25 years experience, nor have I
ever used dry milk except in traveling. However we can obviate the imper-
fect supply by the boiling process, and by giving orange juice.
The question I do want to speak on is the question of premature baby.
He is talking on the stand-point of well equipped muscles and I agree with
him. Unfortunately in my experience, I am ashamed to say that I have not
the experience in Hospital feeding I w^ould like to have. A great many of
these cases occur in private homes on the outside of town. Perhaps three
times out of five in my premature work, I am unable to get breast milk,
therefore we have to resort to something else. I don't know how many of
you saw an article I wrote in Medical Clinics about two years ago. I have
found a valuable aid — you have to be with people that are not as intelligent
as you would like to have them. I have raised some of my babies on whey,
and when they have gotten whole whey instead of skimmed whey, when a
child digests that you can slip off to a simple formula of whole whey. I use
that exclusively in my practice. I think, there are times when you have got
to eliminate the feeding. The vast majority of babies can be fed success-
fully on home milk. When you have regulated the fat and sugar and in-
creased them both gradually then you have almost always prevented your
difficult feeding cases.
Dr. G. S. Mitchenor, Edenton, N. C. : I wHs mighty glad to hear Dr.
Royster say he had never taken a baby away from the mother's breast. In
Eastern Carolina I find quite often where the mother has taken a baby away
from her breast saying she did not think her milk agreed. The mid-wufe
and the mother are responsible. I have recently had sonie very embarassing
experiences and went into a home — the mother was giving this infant —
PEDIATRICS 201
five months old syrup of quinine. The child had not been born when we
passed our last malaria. Some women in the neighborhood told her about
it. We have got to educate our mid-wives because they have it in for us.
I agree with the doctor that a dram of milk, 60 drops is better than none
at all, but if we have a mother who cannot give the child the necessary
amount is it better that we let the child get as much milk on the three or
four feedings and supplement that with cow milk, or would it be better to
let that child have only one or two feedings a day?
Dr. Faison. Take away infant feeding. We would nearly have to go
out of business. I am of the opinion that this treatment ought to begin be-
fore the baby is born. Get this woman in a condition to take care of her
baby — to have her nipples treated.
Another thing I want to say, and I hope these nurses will tell the others
what I say about it — that is you nurses are with a woman in confinement
and with her a month, if that woman don't give a plenty of milk within
30 days you are a mighty sorry nurse, and so sorry that you ought to be kept
out of the profession. God didn't put that breast on a woman to lie around
and do nothing. With the proper massage and proper treatment she will
give the sufficient amount of milk. If you take care of that breast and that
nipple dampened with boracic acid and keep that nipple thoroughly wet and
if the woman is well the breast will give the milk. If you don't do it it is
your fault, and I want 3'ou to feel that responsibility.
You ought not to let your patient have sore nipples and if you don't have
sore nipples you ought not to have a sore breast. The doctor that has a
patient with sore breasts ought to quit the busmess. The doctor is there
during the child's birth and hands the baby over to the nurse and it is
good-bye. All of these things which Dr. Richardson said I agree with. A
baby should have at least an ounce of good milk for every pound he weighs.
With that view he will sure gain. A woman does not bring babies into this
world for the purpose of being troubled with them — they don't want to do
that, if so thev would turn it over to the doctor and put it in the hands of
the nurse saying, "I am not going to nurse it." Such a woman as that is
not fit to be called a mother. The trouble now is to get the women to have
the babies. Rich society women have something else to do, they don't want
to go through nine months and have a baby. The poor people say they are
too poor, they can't have babies. If you take the poor people out of the
country with their birth-rate, how long will it be before we would not have
any people? Our birth-rate in North Carolina stands higher than any other
State in the Union. I was at a house three times in my life when a baby was
born and when the 13th baby was born I beean to feel sorry for the fellow.
I says "why don't you quit it?" He says "Doctor I am poor and that is
the onlv thing that comes to me on credit."
I am going to ask Dr. Richardson a question on supplementary feeding —
if that baby don't get but a dram it is worth more than all the medicine.
The supplcmentar^' feeding should be given after the nursing. The Pepsin
and stuff is not worth all the salt in the water. I have in my lifetime dis-
agreed with Dr. Moore and Dr. Royster both of them, put it down that
all of the mother's milk will agree with the children, but I have never been
able to get away from the fact that it did hurt. I have come to the con-
202 NORTH CAROLINA MEDICAL SOCIETY
elusion in the years of experience that Faglestein and his crowd brought
the best news in the world when they state that protien did not hurt. When
you have a child that fat and sugar hurt you have your protein that you
can go on and make him go on or live on. It is hard sometimes to get the
babies to nurse, the mother's get discouraged. When they do that, I beg
them to get a nurse and let the mother leave home and I tell the nurse,
"If you don't get that baby to eat in three or four daysj I will have you
discharged." These nurses are great institutions, outside of the hospital
they are hardly worth a cent to us today. It will take four hours on the
'phone to get a nurse as long as they can get around the hospital and talk
about the boys and dress and primp up, they will not go in the private
homes. You nurses ought to go on a strike and act like humanitarians —
we need you and we need the babies.
I agree with Dr. Richardson when the babies are crying with colic, they
are crying because they don't get enough to eat. I had a baby in the hos-
pital that I operated on and he was crying, I said, "What is the matter?"
She said, "he had the colic." I said, "Bring me that four ounces of food I
had fixed up for him." I gave it to him and he went to sleep immediately.
Let them hollow and cry, they will grow by that. I agree entirely with
Dr. Royster on the pump business, I think that is bad. If you get the milk
out of the breast it will secrete, it has to come out, that is really the only
way that will make a breast well. If that baby don't take it out it ought to
be gotten out. If that mother will take her breast in her hand and press
it, it will come out. We all agree that mother's milk is the ideal milk for
a baby. I am glad to hear these men sit down on dry milk, it don't do for
me. It is a commercial failure — everybody in town you ask them what
they are doing, and they say, "I don't know anything about it." We have
too good a milk here to send to New York, Europe, Asia and Africa and
buy milk in tin cans that is dry. I have seen the condensed milk do some
good, but with the proper bathing and proper treatment and a mother that
is willing to keep her mind quiet, and play the piano and sing will give
milk and plenty of it.
Dr. Richardson, closing discussion: I want to thank Dr. Royster for
that suggestion of his about the extra bottle. I have mothers to ask me
about that, they say it says to give the baby one bottle a day. A mother
rolls over all during the night and nurses her baby — she should not do that,
as she has to have the rest. If you want a mother to have a chance, ask
her to let the baby go 4 or A^A hours a day. That youngster does need the
extra bottle, in order to get him used to using it. I think the best way
would be to give the bottle just before nursing when he is hungry — but
never give it in place of the breast.
Dr. Smith pointed out the importance of being punctual. I think this
is fine, especially in the beginning. It makes a mother get up in the morn-
ing. I don't believe you can take care of a baby if you are going to sleep
all the morning. I realized that, after I had some of my own, that taking
care of babies was some work. One of them is getting up early in the morn-
ing. I don't 'insist on waking the baby up at tick of the clock, but most of
the babies will wake up pretty close to the time. I don't do the alarm clock
talking that I used to, but. I think the baby will get along about as well.
PEDIATRICS 203
I want to thank Dr. Smith for bringing out the point that I didn't bring
out — I never give the bottle before the breast, if you do that baby will not
do much toward nursing the breast. I tried to dodge the question of com-
plementary and supplementary. The alternate feeding is a curse to the
mother. As soon as she starts to alternate feeding, her milk is going to dry
up. I must confess that I don't know a great deal about bringing up ba-
bies in small communities. I would like to ask you if anyone of you will
try in the next year in your own community and see if you can't get some
woman with a nursing baby, to give a mother of a premature baby a little
bit of her milk after her baby is through. Explain to her that the whole
medical profession thinks that that would be the means of saving Mrs.
Jones' baby.
Dr. Faison : They do that here in Charlotte, and are glad to do it.
Dr. Richardson: That could be done if we use what personality the
Lord has given us. I used to want to look old — I have found that the older
people don't look down upon us because of our y^uth. They believe what
you say if you will say it firmly. I am confident that the mothers are nurs-
ing babies now more just because the doctors are urging it.
So often it is hard for me to get mothers to believe they have enough of
breast milk. I always ask them to let me see their breast and they take it
and push it and no milk comes. Dr. Moore describes a method that any
mother could learn.
First, your implements are ball and thumb and ball of first finger; with
these grasp the breast way back — he says as though you were going to pinch,
come down aim at it — don't come anywhere getting together. The third
movement is pull down. You will get a stream of milk from the breast,
when the breast pump will only bring a little. You will try two or three
times, the mother will scream out because it hurts if you do it quickly, but
you must try it slowly — it is one of the best demonstrations I know of to
show a mother that she has milk. I thought you folks down here were so
up to date that you would not have much use for extra feeding. I have a
man in my ward, who is my Senior, he said, "If four or five percent of mv
babies don't do well on breast feeding I take them off." That man passed
through the stage of thinking he could not feed babies artificially, but now
he can do that, but he has not learned to carry over from the mother's
breast whatever there is in breast milk to make the best baby in after life,
the best standard individually. If that is true that woman is way back of
grandmother who sticks to breast feeding. I think if Ave will let old grand-
ma nature do the trick for us, because she will if we keep the baby on com-
plementary feeding.
Chairman: I want to express to Dr. Richardson the thanks of this
section for bringing us his message. Your paper has been most cordially
accepted and we appreciate it.
LARYNGEAL STENOSIS
L. T. RoYSTER, M. D., Norfolk, Va.
Laryngeal stenosis is one of the most tragic situations known to medicine ;
its relief by intubation is as satisfactory as it is dramatic. There are a num-
ber of causes of difficult or obstructed breathing, resembling, to the casual
204 NORTH CAROLINA MEDICAL SOCIETY
observer, very closely the clinical picture of laryngeal stenosis, and from
which this condition must often be differentiated. Those most frequently
encountered are: post or retro-pharyngeal abscess, peritonsillar abscess,
foreign body in the larynx or trachea and edema of the glottis. The diag-
nosis from retro-pharyngeal abscess is especially important, since in the
latter condition the separation of the jaws by the mouth gag is often fol-
lowed by immediate death.
This paper will deal entirely with membranous croup or laryngeal diph-
theria, and its treatment by means of the intubation tube. There are four
conditions which may call for intubation:
1. Catarrhal or spasmodic croup;
2. Influenzal croup ;
3. Membranous croup or laryngeal diphtheria;
4. Edema of the glottis.
1. Catarrhal or spasmodic croup usually comes on at night, most often
near midnight ; is usually accompanied by a high-pitched, ringing, harsh
metallic cough. It comes on suddenly as a rule and ends as abruptly as it
appears, with the approach of day. It has a tendency to recur for three
successive nights, but during the day is generally unnoticeable. There are
some children who are "subject" to this form of croup, having it with every
slight cold or with any sudden variation in weather, or after over-eating,
in which instance it takes the place of digestive up-set. Unfortunately,
catarrhal croup does not invariably clear up during the day, but may persist
and produce a continued hoarseness and stenosis, which is so severe as to
require intubation. I have never seen an instance of this, but it is said
by many excellent observers to occur. The nearest approach to it
which has come to my attention, was in a case of measles. This
child required the closest attention for about ten days, during which
it was thought, from hour to hour, that an intubation might be required.
During the past winter this child developed influenza during the conva-
lescence from chickenpox. She again developed a severe stenosis.
2. Influenzal Croup. This condition, though observed many years
ago, has come into prominence during the recent epidemic of influenza,
particularly through the writings of Lynah, of New York. He mentions
several types, which it is not necessary to describe here. These cases occur
during an attack of influenza, and develop quite suddenly. If intubation
is needed, it is needed very early in the course of the croup. They are
frequently intermittent and are very spasmodic. They may be so severe
one minute as to almost call for immediatae intubation, while the next
minute the patient may be resting quite comfortably. Some of these cases,
however, pursue the usual course of laryngeal diphtheria, and gradually
increase in severity, but in a much shorter time than in diphtheretic croup,
and finally require intubation.
There is only one method of diagnosis, and that is by means of the
laryngo-tracheoscope. This cannot well be used except in a hospital espe-
cially equipped ; and as far as treatment is concerned, matters little beyond
the necessity for the exhibition of the antitoxin. I am quite sure that one
or more of my cases of the past winter was of this type, though I have no
PEDIATRICS 205
way of proving it. One of these cases developed quite suddenly about
midnight in a child which had had a severe cold for several days. By ten
o'clock the next morning it needed intubation. This child died of bi-
lateral pneumonia at 10 P. M. the same night.
3. Laryngeal diphtheria. There are two forms of this condition, primary
and secondary.
Primary laryngeal diphtheria is, as its name implies, of primary laryngeal
origin; that is, not following or secondary to a faucial infection. There
is no visible membrane, and a positive culture is rarely obtainable, because
of the difficulty of getting into the larynx with an applicator. This diag-
nosis, therefore, must rest entirely on the symptomatology and clinical course
of the disease. This form comes on gradually, irrespective of the time of
day or night; the child is only slightly hoarse at first, but this hoarseness
gradually increases in severity in the course of one to three or four days
until labored respiration sets in with marked retraction of supra-sternal
and epigastric space, as well as the intercostal spaces. Finally, marked
cyanosis occurs, which gives way to an ashy appearance which immediately
precedes death from suffocation. This is the course of untreated cases.
This type is rarely as septic as the faucial or the mixed cases. The reason
for this is that the larynx is poorly supplied with lymphatics. We should
never be fooled by the absence of jfaucial membrane, and should never wait
for a positive culture, when dealing with this tj'pe.
Secondary cases are those which follow or are secondary to a faucial in-
fection, or are concurrent with such an infection. They are apt to be
very septic, and require most energetic treatment in order to save them-
4. Edema of the glottis may develop in the course of any disease, espe-
cially, acute nephritis, or arachitii bronchitis (Jackson), or from food idio-
syncrasy, such as egg albumin. This edema may be severe enough to re-
quire intubation.
Incidence of laryngeal diphtheria. In this vicinity (Norfolk, Va.), as a
rule the largest number of cases occur from January 1st to April 1st, and
the number of cases is rarely in proportion to the number of cases of diph-
theria in the community at the time. This year the conditions have
changed, and I had performed ten intubations before Christmas (four
since). During twenty years of private practice I have averaged about
ten each winter. By far the larger number of cases occur among the poorer
people, but a fair number occur among the well-to-do.
Responsibility. In a large number of cases the parents rarely think the
child has anything more than a severe cold for several days, a physician
often being called when the child is breathing with great difficulty and is
quite cyanosed. But this is by no means always the case. Physicians
themselves have a large share in the responsibility in death from membran-
ous croup. More cases have come to my attention in which the physician
failed to recognize the condition than those in which he was called too late.
Physicians are not careful enough in treating sore throats. It is absolutely
essential to take a culture of every throat which shows a patch, regardless
of its size or location, and not say that a child has a tonsillitis merely from
inspection. In almost every case of secondary laryngeal diphtheria which
has come to me for treatment, the physician has assumed that he was deal-
206 NORTH CAROLINA MEDICAL SOCIETY
ing with a tonsillitis, without ever having taken a culture. As for the
primary laryngeal cases, there is only one absolutely safe rule to follow;
every case of croup which comes on during the day, and every case which
comes on at night, and which does not clear up during the day, should
have antitoxin. If this rule were followed, intubation would rarely be
performed.
Age of occurrence. The vast majority of cases of membranous croup
come on between the first and fourth years; occasionally, however, one sees
a nursing infant which has to be intubated. My youngest case occurred
during the past winter, when I intubated a 2-months' old nursing infant;
which was well advanced in labored breathing, having been stenosed for
three days. This infant coughed up strips of membrane, which, however,
showed no diphtheria bacilli on culture. The child did poorly all through
the tube period (6 days) and died of pneumonia eight hours after extuba-
tion.
Indication for operation. By far the larger number of cases which
come to the operator for intubation come late in the course of the disease
— many of them so late that it is with difficulty they are saved at all. A
number are not saved because of needless delay in intubating. When the
supra-sternal and epigastric spaces are retracting, showing that the child
is laboring for breath, and bringing into play the accessory muscles of
respiration, and the pulse is becoming rapid, intubation should be per-
formed without delay. When the intercostal spaces are retracting with
inspiration the child is in imminent danger, and when there is a cyanosis
the case is desperate indeed. The danger in these cases is rarely from the
septic condition, but rather from the strain that labored respiration puts
on a heart whose muscle fibers are already affected by a disease which has
a special predilection for this particular muscle. The longer the stenosis
lasts without relief, the more rapid and thready the pulse becomes, and
the more hazardous the convalescent period, with consequent death in
many cases after the stenosis has been relieved by a tube.
It is far better to intubate early — even unnecessarily — than to wait too
long. Extubation, as a rule, is performed on the fifth or sixth day. Not
infrequently the tube must be replaced within a half hour, while occasion-
ally it is expelled by coughing at about the right time without needing re-
intubation.
The operation. When urgently needed, the more expeditiously the in-
tubation is done, the better for the child, since, while introducing the tube,
there is necessarily a short period during which all air is shut off. Perfect
success in this operation can only be obtained by one with considerable ex-
perience. I was much amused when asked once by a physician if I did not
think it was better to do a tracheotomy than to make eight or ten attempts
at an intubation. The reply was, that any one who had to make so many
efforts was not sufficiently skilled to attempt it at all. As a rule, from
the time the gag is placed in the mouth to the time the tube is in place, the
obturator withdrawn, and the gag removed, should require about ten sec-
onds. Rarely should it be necessary to make a second attempt.
Dr. Joseph O'Dwyer, the inventor of the tube, always required his
PEDIATRICS . 207
Students to intubate one hundred times on the cadaver before attempting
the operation on a living child.
Extubation is far more difficult than intubation. It is particularly
difficult when it must be done to relieve a stopped tube. When removing
tube at expiratiori of the needed time of its stay, we may take our time and
be deliberate.
The instrument. There is only one type of tube, introducer and ex-
tubator which is perfectly adapted to this work, and that is the O'Dwyer
type, made only by George Ermold in New York. There have been many
imitations, but there is only one genuine. In the selection of a tube it is
essential to choose the right size ; not so small that it will be easily coughed
up, aiKi not so large that it will over-stretch the larynx, and thereby cause
irreparable injury. This error may also result in the child's having to
wear a tube for a long period, if not indefinitely.
The care of cases. No class of case holds the operator on duty more
closely than do intubation cases. He must never be so far away that he
cannot be reached within a few minutes. These cases are essentially hos-
pital cases, and require the service of a nurse especially trained. Now that
the city of Norfolk has a Contagious Hospital, with proper facilities for
handling intubation work, I require all such cases to be transferred to the
hospital, although I must say that I have done some of my best work in
this line, not only in the private homes of the poorer classes, with and with-
out a nurse, but even many miles in the country, where I saw the patient
only at the time of intubation. In one of these cases the tube was coughed
up in an accommodating manner four or five days later, I eventually re-
ceiving it by mail.
Dr. Ruff: In connection with this paper I want to mention a condition
he did not touch on a new disease. Dr. Jackson, at the American Medical
Association called attention to what he called Peanut Bronchitis, due to
getting a portion of the peanut kernels in the lung, which caused an in-
tense irritation to the bronchi and lungs. That was the first time it was
described. He said he had had many cases of it. At that meeting one of
the biggest men in London was present — a Nose and Throat Specialist —
and he had never heard of this condition, but Dr. Jackson has had many
of these cases. Unless that peanut kernel is removed the patient is going
to die. I sent a case to Dr. Jackson and he removed it, and the child got
well.
Dr. Daniels, Goldsboro : I was very much interested in that paper. I
have been practicing Ear, Nose and Throat about seven years, but the
fourth year of my work it fell to my lot to do intubation. It was some-
thing I knew nothing about doing. I had to make several attempts to
introduce the tube. The Doctor said you should introduce 100 on the
dead body before you undertake it on living persons. Last j^ear I read
a paper on that. I described three ways of doing it. One way was
direct method — second method was one described by O'Dwyer, and I de-
scribed one of my own. I claim in that last method that any man does
not have to have experience to use it, it is not hard on the child, it is easy
on the doctor — it is one that any general practitioner can do — any spe-
cialist or anyone else. I will describe this method to you : I wrap my
208 NORTH CAROLINA MEDICAL SOCIETY
patient from neck down, lay him on a table about the height of that one,
perfectly straight head level, you have to have two good assistants, one
to hold the head, and one to hold the body. I don't use the mouth gag,
like that — I use the one that pulls from the front and lower teeth; I use
a headlight, lighted by pocket battery. You can carry that with you at any
time. I use a thin corrugated tongue depresser, one that will not slip on
the tongue. It is made out of pressed steel, very simple and absolutely per-
fect. You open the child's mouth, put this tongue depresser on its tongue,
as far back as you can push its tongue down, pull it at the same time to-
wards the child's teeth, at that time you will notice that the epyglotis comes
in view. The minute this is on a horizontal plane or dropping backwards,
stick the tube directly in it, then you release your tube with the introducer.
I personally drop my tongue depresser and run my finger in the mouth
to be sure that I don't pull it out with my introducer. The first time I
failed on that. I tried it time and time again. You don't turn the child
blue in the face by choking him. You should have a mop to get the mucuous
out. I don't mind doing that now, but I did. If I could have gotten them
off on my competitors three years ago they would have gotten them. The
child is not exhausted when you get through.
My instrument takes too much force for me to engage my tube, conse-
quently I don't know how I have it engaged. I put a stout string on that
tube — some say the child will chew the string in two, but they very seldom
do that. I use a stout silk string.
Dr. Hart, Lumberton: I didn't get to hear all of this interesting paper,
but am convinced from what I heard that the method is very complicated.
I don't know anything about this direct method, but I think the method
that is commonly used is the most practical method. I don't believe it
is necessary for me to try on a dead person 100 times to learn to use this
method. Some of them tried it on probably less than 25 dead bodies. I
had opportunity before the year was out to see five or six of these cases,
which leads me to the belief that this is pretty common in rural sections.
During that year we intubated six children ; three of them were colored.
It is said that two of them coughed up these tubes and died after that. It
is certainly harder to extubate than it is to intubate. You have to use
a small size, because I have seen a child eight years old that you could not
possibly put a tube in over three or four years' size ; but I do believe if the
average practicing physician knew more about it that he could save at least
50 to 75 per cent of these children, whereas death is claiming 100 per cent
without the tube.
Dr. Elias: I enjoyed Dr. Royster's paper very much. I belong to the
class of doctors that would not make a good intubator. I would like to
ask Dr. Royster if one was not able to intubate in the presence of the child
who needed relief at once, what would he do? I also want to commend
what he said about giving antitoxine without waiting for the diagnosis.
Now that the State is furnishing antitoxine for 25 cents for all that you
need, there is no excuse for not having it. The other point is that so many
wait too long.
Dr. Fassett, Durham, N. C. : I have been using a method of intubation
which I found very simple. When I get ready to operate, I put the child
PEDIATRICS 209
in an angle of 30 degrees, with head raised a little. I use a little brush
below the larnyx, pressed up and back. The tube is pressed in the larnyx
and it is picked out. I don't know what the objection could be to using
that method ; it is very simple and can be easily done.
Chairman: I agree with the doctors that it is better to be safe than
sorry. It is perfectly possible for us to know beforehand whether the child
needs that treatment or not. You should know whether that case is going
to have croup next week or month ; whether he has
if he is going to have that, it will be criminal to give him antitoxine.
I wish to thank Dr. Royster for coming before this society.
Dr. Royster: I have had one case that did not have to be in-
tubated. Dr. Elias asked me if a child needed relief, what must we do.
Intubate it immediately, even if no one is at home. I don't think eight,
ten or twelve attempts should ever be allowed. I flatter myself that I
can do intubation with as little trouble on the child as anyone. I don't
know anything about the direct method the doctor speaks of, but I can't
see any advantage in it whatever. I dont know how long it takes him
to do it. No expert intubator ever makes a child blue from using his
finger, and when he does it is time for him not to do intubation. We all
see a child break out with cold sweat — that is more often reaction from
the relief that the child is getting from struggling so long. There should
be in every community an expert intubator, and if there is not one in the
community the rest of you doctors ought to get together and send a man
off to take a course and learn it. I have seen wonderful work in direct
intubation. Winter before last I had one child that came in with laryn-
geal Diphtheria and Pneumonia — she coughed up that tube 21 times. I
know two nights in the snow and sleet I went back and got that tube. That
child can't live outside of the hospital because she can't retain her tube. I
do say this, that there should be at least one expert intubator in every com-
munity, then the rest of you can put yourselves to sleep about the loss of a
child bj' this membraneous croup. He is practically the only man who is
called on for this class of work. For twenty years up to the past winter
I think I got $600 out of all my intubation.
Paper By Dr. D. L. Smith, Saluda.
As I have under my care each summer, at my private Sanitarium and
at the Better Babies Camp at Saluda, N. C, about 200 cases of diseases
of infants, the majority of which have been treated by other physicians,
previous to admittance, for various troubles, it is interesting to note the
difference as to the variety and uses of the various laxatives and purgatives
given to them.
In reviewing the literature on this subject, I also find the same difference
as to the therapeutic value and use of these drugs.
The conviction has grown upon me that the clinical course of a great
many disorders of infants is protracted by the excessive use of drugs and
especially the injudicious giving of calomel and castor oil.
It is a very common history to find a child begin with some innocent
upset and has been given a course of calomel in repeated doses followed
by castor oil, then by other various drugs, which produces a severe intesti-
210 NORTH CAROLINA MEDICAL SOCIETY
nal irritation with mucous stools containing blood ; with a loss of appetite
and a marked loss in weight. These children improve rapidly upon the
withdrawal of the drugs and institution of a rational diet.
Indeed, I think the greatest calamity to many infants, I have seen in
the past two years, suffering with influenza, and in addition, the so-called
eliminative treatment, which consists in giving repeated small doses of
calomel and increasingly large doses of castor oil. Influenza, particularly
in the last epidemic was purely a naso-phyarangeal infection, and nothing
can be gained by the use of these drugs, which I think eliminates many of
these infants.
Calomel and castor oil tend to lessen the appetite and upset the digestion,
and as an undisturbed appetite and good digestion are the most essential
things in combating any disease in infants the use of these drugs is abso-
lutely irrational.
In diarrhoeal cases there is a positive contra-indication for either calomel
or castor oil. For both, as I will show later, have the physiological effect
of an irritant, and as diarrhoea is characterized by an irritation of the
mucous of the intestinal tract, it is self-evident there is no indication fof a
laxative, but first and foremost, for the rest of the bowels and second a
bland and unirritating diet, which is easily digested and lessens the chances
of fermentation and putrifaction.
I have visited the various clinics of every authority on pediatrics in
America in the past few years, many of them being authors of our best
sellers, which are used as text books in our colleges, and in the hands of
our practitioners. It is a singular fact, that these authors recommend and
thereby encourage the use of these two drugs, but never use them them-
selves. Their students who are fortunate enough to come in personal con-
tact with their work are taught differently, but those less fortunate that
use their works as a guide receive a faulty conception of their
meaning, and inadvertently use them and feel that it is right, because these
authors recommend them. I will later quote some of these authorities
with comments.
Another fact that I have observed in my rounds of the various hospitals,
is this striking difference. If the hospital has a separate department of
children with pedriatrician in charge, these drugs are absent. If it hap-
pens that the children are under the same head as the adult patients, calo-
mel and castor oil form the shock troop division in the drug armamentarium.
Castor oil, chemically, consists of a combination of glycerine, fatty
acids and ricinoleic acid. This combination goes through the stomach
unchanged, but in the presence of bile and pancreatic juices it is broken
up into glycerine and cineloic acid. The cineloic acid combines with so-
dium and forms sodium-rincinoleate, which has marked irritating proper-
ties.— ;-Morse and Talbot. All stools contain mucus after a dose of castor
oil. Clinically, castor oil has been used for every known disease an infant
is due to have. It is rather exceptional to see a baby sick that has not al-
ready had the initial dose before the doctor arrives, as it has been so freely
prescribed by physicians in the past.
I have seen many cases of colic in babies a few days old, the cause of
which I could ascribe to no other reason than the dose of oil someone had
PEDIATRICS 211
given. Castor oil is constipating in its effect. Still, in his recent book
on diseases of children, says that he knows of no drug which is responsible
for more chronic constipation in infancy than castor oil. Hare says the
disadvantage of castor oil lies in its taste, the fact that it is oily, that it
tends to produce hemorrhoids if used constantly, and finally that its fre-
quent use, or even a single dose is generally followed by more obstinate
constipation, than existed before, so that the dose must be rapidly increased
in size to be effective. My personal observation of pre-school age, as well
as school children, suffering with constipation, and the various accompany-
ing symptoms, were directly attributable to the innocent doses of castor oil.
In the Journal A. M. M., in The Use and Abuse of Purgatives: "It is
one of the few purgatives that can be given in spite of nausea and vomiting.
At times it stays in the stomach when nothing else will. On the other hand,
the ease with which this subtle poison can be given invites its abuse, espe-
cially in children. As soon as the calomel enters the intestines it is attacked
by the alkaline pancreatic and intestinal juices, which decompose it into
mercury and yellow mercuric oxide. The latter dissolves slowly and in-
completely in the alkaline intestinal Huid. The small quantity of mercuric
ions thus liberated excites peristalsis and at the same time inhibits the ab-
sorption of fluids. These effects are so much greater in the small intestines
than in the colon that calomel is unreliable as a cathartic. The abnormal
amount of fluid in the large intestine may be completely reabsorbed, giving
rise to diuresis instead of catharsis unless its reabsorption is inhibited by a
saline purgative."
Chondunsny, of Vienna, in his study of calomel, found fourteen fatalities
from its therapeutic use. In a series of experiments he found that the pro-
longed use of smqjl doses seemed to be more dangerous than the large one,
but the larger seem to have a more intense action. His research also
showed that the production of bile was diminished after calomel, and also
that the drug had an irritating effect on the kidneys.
Contrary to the common belief, that calomel is an intestinal antiseptic.
Dr. Abt, in his series of experiments, shows that on the day after three
grains of calomel was administered, the bacterial count of the stools rose
from 210 million bacteria per gram to 762 million per gram of the faeces.
Morse & Talbot, in their book on Diseases of Nutrition and Infant Feed-
ing, writing on the subjects of
"Medical Treatment of Disturbances of Digestion,"
"Indigestion With Fermentation,"
"Intestinal Toxemia of the New Born,"
"Treatment of Infestious Diarrhoea,"
recommend a thorough cleansing out of the intestinal tract; the best drug
for this purpose is castor oil — it works quickly, thoroughly and causes less
irritation of the intestine than other cathartics. The dose should be not
less than two teaspoonfuls — it should be given plain.
Castor oil should be tried first, even if the baby is vomiting, because it
is often retained when food and water are vomited. If it is vomited —
calomel may be given in its place. The usual dose is 1-lOth of a grain,
combined with 1 grain of bicarbonate of soda every half hour — until 1 or
212 NORTH CAROLINA MEDICAL SOCIETY
1/^ grains have been given. It is wise to follow it with two or three tea-
spoonfuls of milk of magnesia. And yet, neither of these men use calomel
or castor oil in their hospital practice.
Dunn, on page 173 in his book on Pediatrics, says of Castor Oil: This
is the most useful general purgative for use in infancy and childhood.
Nothing surpasses it in producing rapid and complete emptying of the
bowels. Its chief indication is in various forms of indigestion, especially
those characterized by diarrhoea. Infants and very young children do not
object to the taste, and even older children will often not mind its taste if
it has not been suggested to them that the taste is bad. When the taste is
objected to castor oil may be given with orange juice, lemon juice or brandy.
Calomel: This is a purgative and diuretic, but in children it is used
almost wholly on acocunt of its purgative action. The toxic effects are
renal irritation and stomatitis, but the purgative doses used with children
never produce these effects. Calomel is used as a substitute for castor
oil when vomiting is present and is often useful in the treatment of vomit-
ing, as when given in repeated doses it tends to correct reversed peristalsis.
On a recent visit to Dr. Dunn's clinic at the Infants Hospital in Boston,
I asked Dr. Dunn how many times he had used castor oil and calomel in
the work there, and his reply as well as his associates' was that they had
never used either as far as they could remember. It is impossible to think
that they never admitted an infant in this institution with the above men-
tioned symptoms. I told Dr. Dunn that he recommended their use in his
book, and his reply was that he was going to rewrite it.
Dr. Richardson : I want to thank him for the fine piece of work he has
done. He has done a bit of research work — that is searching literature.
I used to be like most of them trying to get most of the hospitals to back us.
Dr. Smith visited me ; I took him around and took him to this Orphan
Asylum, where the nurse does most of the treatment. When I am on I let
the nurse do most of the treatment. While I was looking at a case Dr.
Smith asked a nurse how often I used calomel and castor oil there. When-
ever he goes to the hospital he does not get out before he knows everything
from the top to the bottom — of course, you know that takes time. You
know there are a dozen names of women and men who are writing one
thing in their text books and doing another in their hospitals. All of us
have gotten to doing that way. Giving a good dose of castor oil.
There is no such thing as a GOOD dose of Castor Oil, and yet everyone
of us say that. The only medicine I ever carried with me was a vial of
1-lOth grain Calomel tablets and I give 1-1 0th grain until I give ten doses.
I thought that would satisfy them.
Chairman: Many thanks to Dr. Smith for this valuable paper, and I
am sure we have all profited by it.
Public Health and Education
IMPORTANCE OF A CITY TUBERCULOSIS SANATORIUM.
Dr. R. L. Carlton, City Health Officer, Winston-Salem.
In mentioning the importance of the municipal sanatorium for tubercu-
losis we wish to go on record as being on very solid ground when we affirm
that the sanatorium is only one of the means of efficiently carrying out a
program in the fight against tuberculosis by a city or community.
After a campaign of a few years' duration we have in my town a tuber-
culosis dispensary, physician in charge of dispensary, special tuberculosis
nurse, district nurses supervising the home lives and treatment of those
in need of their instructions, a system of relief for those unable to provide
themselves with the necessary food and medicines — all of these activities
supported for the greater part by the municipality, as should be the case.
There has been carried on a campaign of education which has accomplished
something toward bringing to many of the people something of the knowl-
edge of the disease and how to combat it.
The purpose of the activities of the tuberculosis division of a municipal
health department are (quoting from a U. S. P. H. Service bulletin)
1. To alleviate the sufferings of the sick and see that they have comfort-
able surroundings and proper care.
2. To prevent the spread of the disease and to protect the well from
infection.
To be of effective service to those who are sick it is necessary to know
of their existence. Here, as you all know, comes the importance of vital
statistics — the prompt reporting of all cases of tuberculous immediately
after an early diag:nosis has been made by the physician, the correctness
of Siritements on death certificates certifying as to cause of death, the im-
mediate following up by a competent person, and by this term is meant a
nurse of training and ability, all cases reported as tuberculosis, the families
and other contacts of persons certified to have died with tuberculosis; the
encouragement of exposed persons to avail themselves of clinic examination
and treatment, if needed ; the constant supervision of all cases diagnosed
"tuberculous" to see that all necessary care of themselves and precautions
as to others are observed — these constitute some of the activities of the
tuberculosis nurse and dispensary.
There should, of course, be other nurses to carry on educational work
in the homes and schools.
Open air schools should be one of the means of every municipality, and
every rural community also, to combat the inroads of tuberculosis. Chil-
dren who are undernourished and anemic should by no means be cooped
up in a crowded, ill-ventilated school room — and neither should the normal
child. It has been most successfully proven that all school children fare
better physically and mentally when their classes are "open air" classes.
The undernourished child should be cared for in a preventorium, where
such is possible. The advanced cases of tuberculosis especially should have
the care of sanatorium treatment. In Winston-Salem we are trying to
carry out these measures as roughly outlined for the care of our tuberculous.
214 NORTH CAROLINA MEDICAL SOCIETY
Dispensary, special physician, specially trained nurse, home supervision,
sanatorium for advanced cases- At the tuberculosis sanatorium or hospital
situated just on the outskirts of the city is provision for thirty-two (32)
patients, with possible expansion to sixty (60). The advantage of the
location being nearby is apparent — the patient does not have a long trip
to make, he may be visited by his friends and relatives, he is much more
content than if sent away a hundred miles or more. The care and treat-
ment of patients in the institution is good. There is every reason from
our point of view that there should be a long waiting list for admission
— for their own sake and for the sake of their families and neighbors. This
condition does not always exist- The speaker agrees very heartily with
Dr. John Dill Robertson, Dr. Rosenau and others that the forcible deten-
tion in sanatoria of incorrigible consumptives will be one of the means of
remedying the tuberculosis situation. The health officer is charged with
the control of contagious diseases, and this power may be exercised with
regard to cases of tuberculosis as well as in cases of scarlet fever or diph-
theria. Education, exhibits, lectures, motion pictures have been used in
the campaign against tuberculosis and much good has been done ; but we
do not depend upon an educational campaign for control of diphtheria or
scarlet fever. It is necessary to establish quarantine and lay down more
or less rigid rules. Every reported case of tuberculosis should be visited
by a nurse or physician and he should be told of the danger to his family
and friends if he continues to expectorate on the floor ; of the danger to
himself if he refuses to sleep outdoors; of the danger of over-indulgence
in alcoholic drinks, and any other instructions necessary. He should be
provided with sputum cups. If at subsequent visits the nurse finds her
instructions obeyed, the patient using his paper cups and not expectorating
elsewhere, and at least the head part of his bed outdoors and that he is fol-
lowing other instructions, then he is permitted to remain at home and all
assistance possible given him there. If, on the other hand, it is found that
instructions are not being carried out, the nurse warns him that upon the
next visit if conditions do not comply with regulations he will be sent to
the sanatorium. Dr. Robertson believes, and so do we, that if every per-
son suffering with open consumption was apprehended and by force com-
pelled to conduct himself in the sanitary manner which patients at the
sanatorium are compelled to adopt, the spread of tuberculosis would be
greatly reduced. Every consumptive who is trained to follow the rules
of hygiene in caring for himself and in protecting his family and associates
against his disease is one of the strongest educational elements we can place
in a community. Some such plan of forcible detention and education would
mean more careful patient and more careful families, it would mean other
cases developing in the family would be given earlier medical attention, it
would mean gradual lessening of infection and very likely gradual elimina-
tion of the spread of tuberculosis.
CITY ABATTOIR AND MEAT INSPECTION-
By Dr. R. L. Carlton, City Health Officer, Winston-Salem.
Various means are used as a protection of the food supply of a city —
among them being inspection and supervision by skilled persons
of all places where foods are handled, stored or sold to determine that such
PUBLIC HEALTH AND EDUCATION 215
places are kept in a clean, sanitary manner; the physical examination by a
physician of all food handlers to determine their freedom from communi-
cable disease ; the requirement that utensils used in serving foods be properly
washed and cleansed ; the requirement that all foods, especially meats, be
sound and wholesome if to be used for human consumption. Regarding
the handling of meats especially, it is our opinion that the supervision of
this part of our food shall be done by a man of experience and training,
preferably a veterinarian from a school of good standing. In Winston-
Salem the slaughtering of animals for food is done at an abattoir owned
and controlled by the municipality, and the arrangement seems to be prefer-
able to that of having one or more slaughter houses owned by individuals.
The city supplies the manager, laborers, meat inspectors and entire personnel
for the abattoir. Every worker coming in contact with the meats under-
goes a physical examination at least once a year — more often if in the opin-
ion of the health officer it is thought necessary — to determine freedom from
disease. All animals are seen by the inspector before and immediately after
being slaughtered and any diseased conditions warranting condemnation
cause such carcass to be promptly tanked for fertilizer. Meats are required
to be left in cold storage at the abattoir a certain number of hours before
being offered for sale.
Fees are charged for slaughtering and after a certain number of days'
storage fees are charged if meats are left in cold storage. Our arrangement
seems to be working smoothly — the meats are thereby kept under close super-
vision — all animals excepting calves and hogs may be slaughtered in the
country, not in the city, by the producer, and he is required to bring such
carcasses for inspection by city meat inspector before offering for sale.
Certain rules are observed as to age and weight of calves and as to condi-
tion of beeves, etc., and in the main our meat inspection as done by the city
inspector at city markets and abattoir is very satisfactory. Of course, meats
shipped into the city by outside packers bear the stamp of the B. A. L, and
while looked after by our inspector to determine decay do not require rigid
supervision to determine diseased conditions.
Discussion.
Dr. J. E. Brooks, Blowing Rock: There is one phase of this paper that
impressed me as of grave importance. Before the fight against Tubercu-
losis can ever progress very far, there must be compulsory detention of the
tuberculous patient in the sanatorium or some institution where he or his
movements can be directed, guided and controlled by those in authority.
In going into a home and making a diagnosis of tuberculosis and giving
instructions as to the management of that case I challenge the doctor, if he
be here, who has had success in getting the carrj-ing out of their orders, to
hold up his hand.
Our work must fail until we get the hearty co-operation of the public
in enforcing our work. The mere diagnosis of a tuberculous patient and
outlining his management may amount to nothing at all, the doctor becomes
discouraged and feels hopeless, and he is hopeless unless the public gives him
that support that forces his patient against his will to take the proper treat-
ment.
216 NORTH CAROLINA MEDICAL SOCIETY
Dr. C. E. Lowe, Wilmington: There is one thing hinted at by Dr.
Carlton, which I have found to be very detrimental in Wilmington. We
have had, for some years, a County Tuberculosis Sanitorium. It has never
been the success it should have been. It was never the success it should
have been before I began to work, nor has it been since. That arises
through the difficulty of getting people to accept treatment in it and that
bears out the statement just made that coercion must be the factor in the
control of a large percentage of cases. I think it has been my observation
that the case that needed control most, the open, free expectorating case,
was the one hardest to get control of. The cases among the poor and illit-
erate are particularly hard to get under control. There are great obstacles
in our present state of public knowledge in regard to getting enforcement
of the law, a compulsory law for detention in open cases. I think we are
coming to that. They are the people, in my mind, who need it — the ad-
vanced cases from the standpoint of protecting the rest of the public- 1
am not speaking of advantages to be obtained from the incipient cases. Dr.
McBrayer is the one to speak of that. Another important thing brought
out in Dr. Carlton's paper is the Educational Value.
Those people you get in the Sanitorium get instructions and they spread
that instruction throughout the county, which is a most valuable means
of spreading that information. It is given them through the Sanitorium.
It becomes a matter of habit, and they carry it out, better oftentimes than
they will under the direction of the physician.
Dr. Lewis, Raleigh:
I wish to ask Dr. Carlton — I was told yesterday that of the total number
of patients that had been admitted to the Winston-Salem Sanitorium that
only four ever left alive. Of course, if that is true, it seems that the educa-
tional value from the Winston-Salem Sanitorium is very small. As a
matter of common sense it does not seem to me that the expenditure of
money for a Municipal Tuberculosis Sanitorium is the wisest method.
I am not accurate as to the number of cases. A movement was started in
Wake for the purpose of establishing a Municipal Tuberculosis Sanitorium,
but it failed. We assumed that 75 beds in that Hospital would accommo-
date one-tenth of the patients, and I am told it would cost $2 or $3 per
day to support a patient. On a basis of 100 patients it would cost about
$100,000 per year to support that institution. It does seem to me that the
money that would be expended on a Municipal Sanitorium, that it would
be practically only a house of detention, from the late cases which we must
bear in mind are not taken into the institution until they are late cases, or
until they have infected the other members of the family before they are
taken away.
In 1906, when I was President of the National Conference of the State
and Provincial Boards of Health, my address was on Tuberculosis. I took
the position that money spent on a Sanatorium at that stage of the con-
test was not spent to the best advantage ; that so far as the cure of the
patient was concerned that would cost about $42,000 a year to run it. I
took the position that if that $42,000 was invested in Health Officers, that
the result would be to educate the people on the subject, and the total num-
ber of cases that would be cured through that method, by home treatment,
PUBLIC HEALTH AND EDUCATION 217
would amount to 50 or 100 more than would be in the hospital. It does
seem to me that the money that would be necessary to spend on a Municipal
Sanatorium to segregate these patients in the last stages, that if that money
was spent for the instruction of the people, employment of skilled nurses,
etc., I believe we would get greater results than we do from the Sanatorium.'
I am more and more confirmed in the idea when we have such a tremendous
proposition to handle and not money enough to take care of more than one-
tenth of them that we could spend it to a much better advantage.
Dr. McBrayer, R. A. : I am strongly in favor of the educational program.
We ought to have a better one than we have. In our aim and struggle I
think at times we have overlooked something that we can right now, in
the three million discharged soldiers we have. They were trained to accept
the hospital treatment for a slight ill. When we find a family that has a
case of Tuberculosis in it, if it is father, son or brother that has much
training in the army, ycu can tell him that this sister, wife, husband or
brother ought to accept Sanatorium treatment, and I bet you 99 times out
of 100 this ex-soldier will agree with you, and he will do his best to get
that person to go to the Sanatorium. They know that Sanatoriums are
the places for tuberculosis patients, and you are doing wrong if you don't
go. I think lots of times when we are doing this educational work if we
made our appeal to or through the soldiers, who are so well trained in the
use of Sanatoriums and the like, we would get better results.
Dr. Lewis: I want to express my great appreciation in the great work
along the educational line, that is being done at our State Sanatorium.
Dr. Carlton : I would like to say, for the benefit of Dr. Lewis that
more than four patients have left alive, because more than that many have
left there without permission. We have no means of forcing them to stay
there. We cannot near take all the patients in Forsyth County. I wish
we could. I would think that we ought to have a number of beds in this
Hospital to be used for educational purposes and educate them how to take
care of themselves and look after the family at home.
REMEDIAL CONDITIONS IN SCHOOL CHILDREN.
Margery J. Lord, M. D., Asheville.
Gentlemen, you are all interested in health problems and in preventive
medicine or you would not claim to be practicing medicine, in 1920. And
yet I am sure to many of you Medical Inspection of school children is a new
phase of nealth work. France began this work when, in. ]P,^\^, she estab-
lished a royal ordinance decreeing that school authorities should look after
the sanitary conditions of the school children. In the United States, Boston
M'as the first city to establish a regular system -.'.: medical inspecti^.n, begin-
nmg m 1894 with a staff of fifty physicians. This work has steadily grown
until now Medical Inspection is provided for by the law in nearly one-
half of our states; regular organized systems of Medical Inspection are
found in about one-half of our cities, while some sort of a beginning has
been made in nearly three-fourths of them.
With this bit of history to refresh your minds, let me now get at the real
purpose of this paper. I have divided my paper into three sub-heads, the
first of which is:
218 NORTH CAROLINA MEDICAL SOCIETY
1. Educational Handicaps: These handicaps concern not only the
physical welfare of the child, but are an economic problem of every city
and state. Here are some facts concerning New York City children : A
child with seriously defective teeth requires one-half year more than a non-
defective child to complete the eight grades. About one-half of all school
children have defective teeth. In the same manner, the child with hyper-
trophied tonsils takes seven-tenths of a year more than he should. One
child in four has hypertrophied tonsils. The extra time required by a
child with adenoids is one and one-tenth years. One child in eight has
adenoids. The pupil with enlarged glands requires one and two-tenths
years longer- Nearly one-half of the children have enlarged glands. These
handicaps to a child's education, therefore, become an economical problem,
and it is a simple matter to compute how many dollars are wasted each year
in the futile attempt to impart instructions to pupils whose mental faculties
are dulled through remediable physical defects. Conservatively speaking,
then, we may say that 60% of all school children suffer from such defects
and that the instruction given these children suffers a loss in effectiveness
of nearly 10% because of physical defects which could be removed. It is
indeed very evident that our problem is of real financial importance.
In Bridgeport, Conn., A. C. Fones, D. D. S., has made some interesting
and instructive observations. He found in 1912 the cost for re-education
in Bridgeport equalled 42% of the entire budget With this fact staring
him in the face and realizing that something could and should be done
to better the health of the school children, Dr. Fones decided that the most
conspicuous defect of the child is the unsanitary condition of his mouth.
On examination he found teeth covered with green stain, temporary and
permanent teeth badly decayed, fistulas on the gum surface showing ;
outlet for pus from an abscessed tooth and decomposing food around and
between the teeth. Why go any further in your examination of the child ?
Right here at the gateway of the entire human system is a source of infec-
tion and poison sufficient to contaminate every mouthful of food taken. If
Dr. Fones were right in his deductions that the most unhygienic feature
of a child's life is its mouth, then clean mouths, sound teeth, and toothbrush
habit should, to a large extent, rid us of educational handicaps. He has
taken up this problem in a very efficient manner, and with a corps of three
dentists and twenty-six dental hygienists, he has accomplished an untold
amount- There are four distinct parts to this system. First — Prophylac-
tic treatment, or actual cleaning and polishing of the children's teeth and
chart examinations of their mouths. Second — Toothbrush drills and class-
room talks. Third — Stereopticon lectures for the children in the higher
grades. Fourth — Educational work in the homes by means of special lit-
erature for the parents. The result of this mouth hygiene has been roughly
as follows: In 1918 the cost for re-education in Bridgeport was 17% of
the entire budget instead of 42% as it was in 1912. This work is of eco-
nomic value certainly. But it does not stop there. This change has been
a vital one to the self-respect of the pupils and in advance of the normal
conditions of the normal children. In 1912, 1,356 children in grades II
to VI, all of whom were in the retarded class and over 14 years old, left
school to go to work. In 1918, less than 300, all in grades V and VI, re-
ceived working certificates. In other words, the children had been edv
PUBLIC HEALTH AND EDUCATION 219
cated to see the value of higher education. They had not been retarded
through physical handicaps and become discouraged, but their clean mouths
and cleanly habits had given them self-respect which in turn made them
wish to really amount to something.
So far I have emphasized the economical side of educational handicaps,
chiefly because a mathematical problem may be proved without any ques-
tioning and when reduced to dollars and cents health problems become more
convincing to a community. You, as physicians, have but to give this
matter your serious attention to bring before you the possible wrecks of
adult life because of defects which should have been removed in childhood.
The mentally deficient, the blind, the deaf, the deformed, undernourished,
anemic specimens, advanced tuberculosis, organic heart trouble and the like.
I\Iy second sub-head :
2. Medical Inspection: There is no one present, I hope, Avho will
not agree that school children have defects which are hindering them from
pursuing their studies either because of frequent absences due to illness or
actually making them incapable for their work. The first step, therefore,
is to find these defects — to seek out the reason that some children "just
can't keep up" with their studies or are absent one week each month. We
as a state say these children shall go to school, whether they be rich or poor,
bright or dull, healthy or sick. Should we not, therefore, be responsible
that the child be in the best possible condition to receive this required educa-
tion and derive every benefit therefrom? Is it not up to us to remove every
possible stumbling block from his path so that physically as well as mentally
he will beccme a well rounded and as nearly as possible perfect citizen of
our United States? This is what medical inspection and medical inspectors
are trying to do, to back up education with health.
Some may argue that it is the parent's duty to take his child for frequent
examinations to the family physician. That would be excellent, but there
are three drawbacks: First — The majority of parents would never take
the trouble to do this. Second — The family physician, when asked to look
the child over, "chucks" him under the chin and asks a few vague questions,
prescribes a tonic, and the interview is at an end, without the doctor even
looking at the boy's mouth and throat — let alone stripping him to the waist
and examining his heart and lungs. Third — The expense, if the physician
does examine the child and makes a proper charge, the parents will consider
it useless to throw away that amount of money on Johnny "when he really
i?n t SICK-
The medical inspector makes a uniform examination of each pupil and
after each examination keeps a record of it, and this record is kept in the
school building with the child's report cards. There it is in a nutsliell,
the child's physical standing as well as mental. The physical examination
card has room enough to record four examinations on it, thus showing any
changes in health throughout the grammar school, at least.
There are many other duties of the medical inspector besides purely the
physical examination of the children. His duty, in my opinion, covers
anything whereby the health of the school children will be improved. But
as my paper is dealing with the children themselves I will not warider too
far from my subject.
My third and last sub-head is my real reason for writing this paper.
220 NORTH CAROLINA MEDICAL SOCIETY
3. What Shall We Do With These Defects? I want each one
of you to ask yourself this question. What shall we do with these defects
these educational handicaps revealed to us by medical inspection of our
school children? Can we, who are medical inspectors, spend our evenings
congratulating ourselves on a big day's work because we have examined
thirty children and sent cards home notifying the parents that twenty of
these children had some defects which we wished corrected at once? This
is but a waste of time and paper if we stop here. Our influence must be
brought to bear on the parents themselves and they must be made to see
the necessity of the treatment advised for their children. Here is where the
school nurse is indispensable. She goes to the home, talks to the mother,
leaves a health pamphlet and possibly comes away feeling there is no use
to waste time in that home, but eventually, when she has made four or five
visits, the parents are convinced that the child should have his tonsils
removed or hir teeth tilled or whatever the defect is remedied. Now comes
the hard part. The parents can afford to pay something and their pride
makes them want to, but they know they can't afford a specialist's fee. What
is to be done? The Medical Inspector has found the defect. The nurse
has educated the family into being willing for the operation. The specialist
will do the operation gladly for nothing, but the people won't submit to
that. One way has been provided by the State Board of Health in their
tonsil and adenoid clinics. They look upon school children as all being
equal and make a charge of $12-50 for each tonsillectomy, planning to do
enough operations in one day to permit about four children who are too
poor to pay to be included and paid for by the $12.50 from the others. In
this way the surgeon may receive the sum of $100 per day for his services
and all expenses of the clinic defrayed by the children themselves. This
plan certainly has many advantages and has provided a means whereby
many of the rural children have received surgical aid this past year. Rut,
like every good thing, this has been criticised. It was thought by some that
the sheep and goats should be further separated and the rich made to nay
the specialists fee, and hence refused the clinic.
The Buncombe County Medical Society has adopted the following plan:
"The committee appointed by the Buncombs County Medical Society
to devise a plan for organizing a tonsil and adenoid clinic in Asheville, begs
to submit the following recommendations:
1. That the public at large, regardless of age, includmg not only those
of tichool age, but th.se above and below that period, ha>e the piivileges
of the clinic.
2. That the privileges of the clinic be extended not only to the City of
Asheville, but to Buncombe County.
3. For the purpose of defining the object and the scope of the clinic that
the public be divided into the following classes:
A. Those who are unable to pay a hospital fee.
B. Those who are able to pay a hospital fee and no more.
C. Those who are able to pay a clinic fee of ^U2.50 and no more.
D. Those who are able to pay more than the clinic fee.
4. In order to provide for those whose means place them between Classes
PUBLIC HEALTH AND EDUCATION 221
A and B, and between Classes B and C, and that no one may be denied
the privilege of contributing to the support of the clinic according to his
means, that flexible limits be placed on Class B.
5. That the privileges of the clinic be extended to Classes A, B and C.
6. That Class D be referred to their family phj'sician for advice.
7. That each applicant for the clinic must bring from his family physi-
cian a written statement as to which class he belongs, or what fee he is able
to pay.
8. That the clinic be held in the three general hospitajs of Asheville and
Biltmore, North Carolina, all three of these hospitals having generously
offered their hospital facilities for the purposes of the clinic, conducted as
herein set forth.
9. That all clinic fees be collected by and apply to the support of the
hospitals.
10. That the clinics be conducted in the various hospitals from day to
day as applicants present themselves and as facilities permit, rather than in
large groups.
11. That the managements of the various hospitals be requ -sted to co-
operate in developing further details of the clinic.
12. That the co-operation of City and County health ifficer> he solicited.
13. That no physician make any charge for services rendered in the
clinic."
But we find more defective teeth than we do tonsils and adenoids. We
could keep every dentist in Asheville busy filling children's teeth. A dental
clinic is just as important as a tonsil and adenoid clinic- Last summer we
had a chance to see what the State Board of Health was doing along this
line when they sent Dr. Schultz to us, who in six weeks' time based on our
local charges did work amounting to $2,500 on our school children. The
authorities of the city of Asheville have already signified their willingness
to furnish funds for the equipment of a dental clinic, and it is my hope that
next September will see us ready to start the school year with a permanent
dental clinic — operated by, if necessary, only a part time dentist, whose
salary shall be paid for by both county and city, thus giving the children
of the county the same privilege as those of the city.
The school nurses are doing all in their power to prevent dental decay,
by toothbrush drills and by making it possible for every child to own a tooth
brush. From the Prophylactic Company children's tooth brushes, factory
seconds, can be secured for the children at 6c each. Many gross of these
tooth brushes have been sold to the children this year. The Modern Health
Crusaders Movement, literature published by Dental Manufacturing Com-
panies and the Metropolitan Life Insurance Company, has done much to
interest the children and parents in the proper care of their bodies, the
necessity of plenty of sleep for growing children and the value of regular
meals composed of nutritious food. All this is doing its part to improve
the physical standard of our school children.
To summarize them: Medical Inspection began in this country in 1894
and has increased until now three-fourths of our cities have some form of
222 NORTH CAROLINA MEDICAL SOCIETY
Medical Inspection. Physical defects which mainly are — decayed teeth,
adenoids, hypertrophied tonsils and enlarged glands, are educational handi-
caps, which, if properly attended to in early child life, would relieve the
state of a large financial burden due to the cost of re-education of retarded
children. Medical Inspection has become a necessary part of preventive
medicine practiced by every board of health, but Medical Inspection is
pow^erless to reach its full value unless a means be provided which will
amply and adequately give the public a way to have these defects treated
which will bear in mind the fact that all people have a great deal of pride,
that very few want to be on a charity list. Yet many have a nearly empty
pocketbook.
In concluding, gentlemen, let me urge you to a candid discussion of this
paper. I am expecting to learn more from your discussions than you have
from my paper.
Discussion.
Dr. George M. Cooper, Raleigh : I wish to emphasize the fact that
Dr. Lord in her grand paper has sounded the key note of this profession.
She stated the financial problem was the key note of the whole thing. She
brought out another important problem. That is "To back up the educa-
tion of the children with health." I think that is the whole thing in a nut-
shell. As to the Asheville, Buncombe County, plan for getting this work
done, I think it will succeed. I don't know of another place in North
Carolina where it would succeed. That is that the Medical Inspector and
those three skilled employees will camp on the trail of every physician in
that county. I would hate to be the doctor that would prescribe a medicine
for diseases of the throat and let one of these people find it out. I will
close by saying that four officials are four sulid bricks in Asheville.
F. H. Richardson, Brooklyn, N. Y. : I wish to thank Dr. Lord for one
idea she gave me, that is practical application of a way to put across the
corrections after you have found them. We have been working this along
with ideas that originated in Boston for Tuberculosis. We get children
from the general clinic, who we find undernourished and take in our case
the weight, where she takes the retardation. We find the teeth common
and tonsilis and defective heart quite common. Eye defects common. We
find we can never increase the weight until we get the tonsils out and teeth
cleaned up, until we can get the youngsters to get those things done, no
matter what he does he will not gain weight. Another thing is getting
20 to 60 children together with their parents, if they can come, and put a
little boy scout in it. Say a little boy has a chart and he sees a two or three-
ounce gain, and we give a certain prize if he gains one-half pound or one
pound, and it is surprising how keen those children are to get that prize.
They make their parents do things that they don't want to. The children
are the ones who initiate the improvement. The New York City Board
of Health tried getting the family physician. They brought out the defects
found by the family physician, and the Medical Inspector had it on the
family physician. They could not get enough family physicians to make
this inspection. It is very interesting for me to find how large a proportion
of the special practice can be composed of mere children. They are urging
me for treatment.
PUBLIC HEALTH AND EDUCATION 223
The Tj'phoid inoculation and all those things are being urged by the
people, and the doctor who is not prepared to do that has, in my mind, a
very serious responsibility. The hospitals seem to set a good example to be
followed by the city when they urge the establishment of school examina-
tion. I think the hospitals can well set the example.
Dr. Lewis, Raleigh: As the oldest specialist in North Carolina and a
man who has been associated with Public Health work in the State thirty-
odd years, I feel it my duty to say a word or two. I think this work that
is being done by the clinics is extremely important, and I think the present
plan that has been devised is the best plan- As I understand, at Asheville
the children are brought to the clinic. And for the reason that the rich
man can't bring his child to the clinic and have him operated on for any
less than the specialist will charge. You will see, I think, in a moment
how it is that the clinic conducted upon the present plan is one of the best
methods ever devised for the purpose of advertising the business of the
specialist.
These clinics are held in a certain county and a number of defective
children have been operated on in these clinics, and they go back home and
the neighborhood w^ill see the effect the operation has had. The clinic is
not held in that county for a long time after that. What is the consequence ?
The consequence is that the people knowing they could not get advantage
of the clinic for twelve months send their children to the specialist. The
specialists who do these operations have nothing to lose from the financial
point, but everything to gain. There are thousands of children in this state
who need to be operated on, and a'majority of those would never be reached
if not by this method. This will not only be the means of extending benefit
to a larger number of children in the community, but of putting more dol-
lars in our pockets.
If there is not something else in the Medical Profession besides money,
I think it is time for us to get out. In contrast to the attitude that the
physician is after the money, ignoring the welfare of the community, I
want to tell you a beautiful story of Erwin Cobb. He said : "The story
I propose to tell j^ou now, the beauty of it, is that it is true." He said that
in one of our Southwestern towns there lived a Dr. Thomas Lyerly, a coun-
try doctor. The rich people had never heard of him. His practice con-
sisted of down and outs and drunkards. He had an oflUce in a respectable
building for a while and something came along and he had to move, and
the only place he could find for an office was over a Livery Stable. He
took a plank and painted a sign on it — "Dr. Thomas Lyerly, his office is
upstairs," and nailed that to the stable. He had a call several miles off,
and as a result of exposure he contracted pneumonia- He came home, went
to his room and locked the door. In a day or two they missed him and
found the door locked and broke it open. There lying on the bed was Dr.
Thomas Lyerly, with his old account book and pencil in his dead hand, and
he had written across each account, "Paid in full." He was taken to the
cemetery, and these people followed him on foot, no carriages. They came
back to town and were discussing that they ought to put a monument over
his grave. They took up the post on which he had painted this sign on it,
and planted it at the head of his grave —
224 NORTH CAROLINA MEDICAL SOCIETY
"DR. THOMAS LYERLY, HIS OFFICE IS UP STAIRS."
I think when we compare that, we can say there are thousands of them
in this country. When we compare that attitude towards humanity, I
don't believe any of you have it in your heart to say that this society is out
for the love of monej^
Discussion closed. Dr. Lord: I want to say, gentlemen, that the clinic
I outlined is at work in Asheville. We have been decidedly handicapped,
but we are running it, and next year I hope we will be able to report what
has been done.
I will say that the only thing we have done of much importance is to
get weight charts from the Colnos Dental people. They send us large
charts that will hold the names of between 40 and 50 children. We try
to have one in each room in each school building and record the weights of
the children on this chart. On a table in one corner is correct weight, age
and height. We hope to get up to the standard.
These clinics that have been held by the State Board of Health or by
any city, for tonsils, adenoids or dental, I think the highest value is un-
doubtedly the educational. The weight and health of the child cannot be
improved unless these defects are removed. In order to do so we have cer-
tainly got to educate the parents-
Dr. George M. Cooper, Raleigh: Before reading my paper I wish to
express my cordial appreciation to Dr. Lewis for the power of strength he
has been to us in the past. For the benefit of some of the younger men
and women. Dr. Lord may not know that Dr. Lewis was the first recog-
nized specialist of ability in the State of North Carolina. For forty years
or more he has maintained his position all the time in his profession. This
generation will never know how much good he has done in the world, and
I wish to commend his admirable spirit, in placing his service before money,
to some men in our profession.
THE STATE PLAN FOR SECURING MEDICAL AND DENTAL
CARE OF SCHOOL CHILDREN.
By G. M. Cooper, M. D.,
Director Medical Inspection of Schools, State Board of Health, Raleigh.
On assuming the duties of Medical Inspector of Schools for the State
of North Carolina some five years ago, and after having had a previous
experience of two years in county work of this nature, it did not take but
a short while to reach the conclusion which every experienced person engaged
in this work soon reaches, that medical inspection that does not provide a
systematic plan of follow-up work is practically worthless.
Anything short of a State plan for meeting the many problems that one
confronts at every turn will not be satisfactory. There are certain things
to do which must combine the preventive with the remedial problems. In
the first place, every inspector soon finds that the epidemiology division
must function properly or the schools are demoralized for a certain period
during each session. Parents of perfectly well, healthy children will be
found keeping their children at home because of the fear of whooping cough
or measles, and the children of careless parents will be found spreading
PUBLIC HEALTH AND EDUCATION 225
such infections in the schools. So the first thing that has to be done, is to
see that the well children are not penalized by the few careless patrons of
the school. The intelligent and watchful interest of the teacher is abso-
lutely essential. Again, in practically half the State every year as soon as
the schools settle down to work after the Christmas holidays, outbreaks of
smallpox "begin to demoralize the attendance again, especially in the country
districts where compulsory vaccination against smallpox before entrance
in school is not enforced. So we find that often 90 per cent of healthy chil-
dren are kept at home certain days because 10 per cent of the children may
have been thought exposed to smallpox. The only sensible thing to do in
this matter is to require county-wide vaccination against smallpox before
children are admitted to the parochial or public schools. But the real big
problem with which medical inspectors should be concerned is in the cor-
rection of physical defects after found.
The State Board of Health of North Carolina has developed a systc;
of caring for defective children, both surgical and dental, which has been
carefully worked out over a period of several years, and is primarily based
on necessity. The first effort was directed toward the care of the school
children's teeth because of the fact that about 80 per cent of the chiuren
enrolled in the schools of the State were known to have need or dental treat-
ment. On July 10, 1918, we started the first systematic work in this field.
The plan, as everyone here knows, is to take the dentist to the children out
in the school houses or in convenient country centers, whether the schools
are in session or not, and have the children from six to twelve years of age
who are known to be in need of dental treatment brought to the dentist
for the simple forms of treatment. Each dentist is equipped with a portable
outfit and the emphasis is placed on prophjdaxis. The idea here is to cause
a state-wide awakening of all the people from the homes of the wealthiest
to the remote cabins of the poorest of the State's children to the necessity
of dental care at the right time for the teeth of every child. We need not
go into figures, but simply state that the importance of this move is becom-
ing more and more appreciated by responsible people throughout the length
and breadth of the State.
The problem of carrying surgical aid to children suffering from the more
common defects of childhood, such as diseased tonsils and adenoids, has
been much harder to solve than the dental care, but the necessity of some
solution has been no less imperative. After an experience, as stated
in the beginning of this paper, of several years, based on careful medical
examinations and observations in many counties, it has been found that
there are no less than fifteen out of every hundred school children enrolled
in the schools of the state suffering from diseased throats demanding opera-
tion by competent throat surgeons. These defects have been so patent
that the teacher, the parent and even the neighbors readily assert that some-
thing is wrong and ought to be remedied. Some of these children have
tubercular or rheumatic ancestry either direct or closely collateral. None
of them without the operation can be reasonably expected to develop into
healthy men and women without such operations at the proper time. It
has been learned beyond question that less than 1 per cent of such childreit
ever even consult a specialist and less than 10 per cent ever taken to the
226 NORTH CAROLINA MEDICAL SOCIETY
family physician. We have found in the majority of such cases that the
average fees of specialists are beyond their reach ; but what is a much nn^re
difficult problem, there is widespread fear of the operation, ingrained belief
that it is devised for the enrichment of doctors and specialists. So, primarily
to dispel such foolish beliefs and at the same time to convince the most
doubting that the sole purpose of this operation must be for the benefit
of the children and the children alone, and finding that in order to do this
the only possible way to do it was to adopt mass strategy, the organization
of what we have been pleased to term tonsil and adenoid clubs has naturally
been the logical step- It is not necessary here either to go into details, but
to simply state that these clubs have been devised and put into operation
successfully in enough counties and different sections of North Carolina to
create a wide-spread interest in the operation and what it means for the
children. The specialists engaged in the work have been amply paid for
their service, the people have not been pauperized and the whole thing has
been taken out of the haze and fog of commercialism to the everlastmg
benefit of the children, for whom every medical inspector and every school
authority in North Carolina should be most concerned- The future of this
work for the children of the State depends to a great extent upon the sup-
port, financial and moral, of the medical profession and the teachers and
school officials, high and low, in the State of North Carolina.
Discussion.
Dr. S. A. Stevens, Monroe, N. C. : It has just happened that an Adenoid
and Tonsil Clinic was conducted in my county week before last. I think
they operated on about 82. They turned down over 100 in the county,
and did not get to operate on any of the town children. So far as I have
been able to learn from comments of the people at large, it certainly has
met with the approval of the public. I think if you will put it on a selfish
basis, let them have no other thought, but that I am fully persuaded that
it will be of benefit to the specialists themselves financially. In the first
place it makes the people acquainted with the specialist who does the work,
and for every case that he operates on at that clinic I have no doubt that
he will get at least five cases that will come and pay him his full fee. If
they want to put it on a selfish basis, I think it is a good thing for the
specialist himself and a great benefit for the ones that are operated on. My
people are begging for another Clinic. I hope the State Board will be able
to put these Clinics on as often as necessary until we get all these things
cleaned up. I think it will do as much good as our Typhoid campaign did.
We gave the Anti-Typhoid Treatment to ten patients.
Dr. Lewis, Raleigh : As you gentlemen all know, I am extremely lame
from a joint disease Tuberculosis at the age of 2^ years.
My oldest grandson was visiting me last summer ; he complained of his
knees and limbs precisely like my old attack began. When I heard him
crying you can imagine what dagger that was in my heart. My son carried
him to the University of Virginia, and they decided that he had Tuber-
culosis of the joint. Dr. Holt examined him and ordered that he be put
to bed and have his tonsils removed. He was kept in bed with this bandage
on one month, and then it was taken off. He was kept in bed another month
PUBLIC HEALTH AND EDUCATION 227
without the bandage, and in two or three weeks after that he was turned
loose, a perfectly well and strong boy. This is a striking instance of the
value of the removal of affected tonsils.
Dr. Laughinghouse : There is one' point in this discussion that has not
as yet been touched upon, and to my mind it is one of the most important
points that we have to consider in perfecting a program for tonsils and
adenoids. The point is that 82 per cent of the people in North Carolina
are rural people. If we do not have some glaringly, impressively, almost
forcible plan, to bring to the attention of the rural father and mother the
necessity of removal of tonsils, we will for a long, long time be greatly
behind in this undertaking.
Asheville, Charlotte, Winston-Salem and cities of such size can very
easily handle the proposition within their own corporate limits, but I 'loubt
if they are able to handle it right aw^ay outside. We had in Pitt County
a Tonsil Clinic; it has 50 to 60 thousand inhabitants. The man who did
the work was a nose and throat man in the county. He operated on some-
where between 20, 30 or 40 patients for two daj^s for the Board of Health.
His work has more than doubled since that clinic. That is what it means
to the Specialist, and if the Specialist sees fit to look upon this proposition
from a selfish motive or from a financial viewpoint only, if he does not care
whether his office is up stairs or down, he is bound to see that this is a good
form of advertising- Say if we give him an opportunity to hire an advertis-
ing manager, he can't to save his life get before the public the actual value
of the job quite so well as the North Carolina Board of Health is putting
it before the public. I verily believe that the Eye, Ear, Nose and Throat
man who is opposing this proposition because of encroachment upon his
privilege, I believe he has well developed myopia.
I sincerely hope that Dr. Lewis, with his long experience, can take them
in his office and see if he can't clear away this shortsightedness that is in
their financial eye. In addition to that, the people of North Carolina are
iiot an easy people to satisfy. Charlotte can do it, Asheville and Winston-
Salem can do it, and a number of the other great big towns. But we can't
classify 82 per cent of these people ; it is impossible for us to do it. I know
men w^ho took their children to the Board of Health clinic and paid the
$10 or $15 and went to some of their neighbors, some who were poverty-
stricken, and brought their children to the Nose and Throat men and paid
the fees out of their own pocket that the doctor charged. There is nothing
that we can do that will help the Tonsil and Adenoid work as this Clinic
work has done.
The dentists will tell you that Dr. Shultz sent into their offices five or ten
times as much work as he himself did, or they would have gotten had he not
been there.
OUR TUBERCULOSIS PROBLEMS.
By Dr. B. O. Edwards, Asheville, N. C.
There has been so much said and written on this subject and so little
seemingly has been accomplished that I hardly know where to start to
discuss it.
There were 42,274 deaths in North Carolina from all causes in 1918.
228 NORTH CAROLINA MEDICAL SOCIETY
Of this number 7,948 died of influenza. and 3,412 from tuberculosis; 1,793
of these were colored and 1,615 white. This is the official report by the
Bureau of Census at Washington. I was unable to get the figures for 1919.
Dr. L. B. McBrayer states that we have at present 9,500 reported cases
of tuberculosis in North Carolina, and he estimates that 3,000 of these are
colored. I would estimate that we have at least as many more cases in the
State that have not yet been diagnosed and reported. We have one State
sanatorium and two county (at Winston-Salem) tuberculosis hospitals to
take care of all this number and while there has been a great deal of good
work done in the State institution both directly for the patient and also in
an educational way,
After having visited a number of our best tubercular institutions in the
United States and studying the different methods of management of tuber-
culosis patients here and having had the privilege of visiting more than
thirty of the best tuberculosis sanatoria in Central Europe, scattered through
England, Scotland, Ireland, Switzerland, France and Italy, as well as a
great many of their tuberculosis dispensaries and several open-air schools.
And having studied and observed their methods carefully I am thoroughly
convinced that the modified Edinburgh scheme, originated by Sir Robert
Phillip of Ediburgh, is far superior to any I have studied.
Pennsylvania has adopted a modification of the Edinburgh scheme and
is getting good results.
The Edinburgh Scheme consists:
1st, of the tuberculosis dispensary; 2nd, of a Sanatorium for early cases;
3rd, of a Hospital for advanced cases; 4th, of a Tuberculosis Colony for
those that improve, but need a more prolonged treatment ; 5th, of an Open-
Air School.
Taking up in detail the Edinburgh Scheme of the tuberculosis organiza-
tion, the London Dispensary. will be described. London is divided into 29
metropolitan boroughs, including the city of London, and the population is
approximately 5,000,000, carrying in different boroughs from 50,000 to
250,000. There is one dispensary for each borough, and the total number
of dispensaries has been determined by the number of governmental units
rather than by the medical requirements of the situation from the standpoint
of tuberculosis. The -dispensaries are under the Public Health Department
of the London City Council. Several of the dispensaries have only been
in operation for a short time, while a few of the others were established
about ten years ago.
The Paddington Dispensary at 20 Talbot Road, which I had the pleasure
of visiting several times, is one of the oldest and best -equipped, and was
opened in 1909. The medical work is of a high order, and is done by Dr.
R. S. Walker, a trained tuberculosis doctor, who devotes his entire time
to this dispensary -and its patients. Special hours are arranged for new
cases. Old cases and working adults- These latter attending evening sessions
of the dispensary.
There remains much yet to be done that could be done if we had adequate
facilities for caring for several hundred more patients each year. There is
usually a long waiting list and it often takes several months for them to gain
PUBLIC HEALTH AND EDUCATION 229
admission. I find that many of the patients treated there do well and show
marked improvement, but have to be discharged in about four months to
give room for others and often go back to their homes and former conditions
and relapse and die ; where if they could have had twelve or sixteen months'
treatment in the .institution they might have been permanently benefited
or cured.
All caes of tuberculosis who desire treatment are examined and a suitable
form of treatment is decided upon and advised. At the same time useful
advice and instructions are given on the subject of diet, ventilation, sputum
disposal, occupation, etc.
Some throat work, but routine laryngological examinations for all new
patients are not carried out. There is no service of radiology at the dis-
pensary, and adequate records of all cases are kept in convenient files. The
patients receive medicine there, and are expected to pay two cents for con-
sultation.
An open air school (The Kensel House) is closely affiliated with the
dispensary. This is an admirable institution and is efficiently managed.
Hot coca is served at 10:30 and an excellent lunch at noon, for which the
children pay seven cents.
During 1918, 700 patients were treated at the Paddington Dispensary,
of whom 22 per cent were definitely tuberculous and 25 per cent were
classed as suspects. A reasonable amount of follow-up work in the home
was done, and the quality of the social service is excellent and is done by
trained social workers. The whole time and one part time worker is em-
ployed. Local tuberculosis care committees which are a compartively recent
development form a part of the organization of each tuberculosis dispensary
in London. This is an example of the dispensary systems of the scheme.
I found this carried on about the same, with some slight modifications, in
Edinburgh, Aberdeen and Glasgow, Scotland, also in Dublin and Liverpool.
Farm Colony System.
I had the privilege of visiting the Cambridgeshire or Papworth colony
in England and Edinburgh or Polton colony and Hairmyres colony in
Scotland last year.
I will describe briefly the Hairmyres Colony Scheme. The scheme em-
braces a large sanatorium and work colony at Hairmyres, located nine miles
from Glasgow, Scotland, in an agricultural parish lying a little more than
500 feet elevation above the sea level and situated within easy reach of
Lanarkshire. The Hairmyre Scheme is of a special character and is fairly
representative in its object and purposes. It proposes to deal with those
cases of tuberculosis which have so far advanced and improved by institu-
tional treatment that it is expedient the treatment should be continued and
extended in such a form as will restore the persons affected to a condition
that they are again fitted to take up active work. At Hairmyres the
Local Authority have lands extending to about 300 acres, and it is proposed
that the persons transferred there should be under medical supervision, un-
dertake graded labor of a character suitable to their condition, and at the
same time be trained in different occupations connected with work on the
land, so that they will be fitted to follow and obtain their living from an
230 NORTH CAROLINA MEDICAL SOCIETY
outdoor life in the future. Children will also be treated at the Colony.
The capital cost of establishing the scheme is estimated at about 150,000
pounds or $700,000. The necessity for the inception of a Farm Colony
as an indispensable part of the scheme for dealing with tuberculosis has
been unreservedly recognized. It is found from past experience that simply
to afford Hospital or Sanitorium treatment to persons affected with the
disease and then to discharge them with no alternative but the resumption
of their former occupation, which in most cases is wholly unsuited to their
conditions was entirely futile. At Hairmyres, as already mentioned, graded
labor is provided and instruction is given in farm work, market gardening,
poultry and pig raising and elementary forestry work, and in connection
with the forestry a tree nursery has been established at Hairmyres.
At Hairmyres, up till December 1, 1919, only children had been treated.
The Scheme not having been at the stage that adults could be admitted.
The buildings and the Scheme generally, however, were practically com-
pleted and would be available for the reception of patients within a month's
time. Accommodations have been provided for 250 to 300 patients. The
Pavilion stands at an elevation of 580 feet above sea level. They are of the
Butterfly type, and are erected on the ridge of a general slope facing the
south, thus ensuring the maximum of sunshine ; they command a magnificent
view of the surrounding country. The pavilion administrative block and
associated buildings are spread over an area embracing thirty acres. An
established belt of trees gives adequate protection from the North, and
Shelter Belts have been planted to acord cover from the prevailing winds.
The buildings are fitted with all the most modern appliances. There are in
residence at Hairmyres an experienced Physician-Superintendent, Mr. A. M.
McPherson; a Matron and stac, a Farm Manager and assistants, a fully
qualified Dairymaid and assistant; a Head Forester and assistants, and a
Head Gardener and garden laborers.
Those members of the staff have been selected having in view not only
their qualifications for the work under their charge, but also their suitability
by temperament and otherwise for working and training the patients at
the Institution.
In conclusion, I advocate a modification of this scheme to suit our scat-
tered population, which should consist of a dispensary in each county, and
a doctor the whole time, health officer where there is one employed, or the
county physician and one or two nurses specially trained for this work. Also
a tuberculosis doctor as consultant who could serve in about four counties
and should visit each dispensary at least once each week and consult with
the doctor in charge.
Also the building of a new hospital with ample room for the early cases.
The doubling of the capacity of the present institution for advanced and
moderately advanced cases, the establishment of a tuberculosis colony for
those showing improvement and requiring a more prolonged treatment. A
new and separate institution of like nature for the colored people.
To do what I have outlined will cost money, but what better investment
could the great commonwealth of North Carolina make than saving the
lives of thousands each year from the great White Plague? The best in-
vestment any state or nation can make is to care for the health of its people.
PUBLIC HEALTH AND EDUCATION 231
The state has provided amply for the deaf, dumb and blind, for the insane,
ample room and attendants are provided ; yet for the thousands afflicted with
tuberculosis, who have not the means by which they can get the proper care
and attention professionally at home, we have only one sanatorium for
the entire State- It is up to us medical men to stand together as a unit
and make an earnest appeal to the State to lend a hand to help our cause
in this, the most terrible and surest life destroyer within the confines of its
borders today.
May I close by quoting the words of a consumptive — Washington Irving:
"What, after all, is the mite of wisdom that I could throw into the mass
of knowledge, or how am I sure that my sagest deductions may be safe
guides for the opinion of others but in writing ... if I fail, the only evil is
my disappointment; if, however, I can by any lucky chance, in these days
of evil, rub out one wrinkle from the brow of care or beguile the heavy
heart of one moment of sorrow, if I can now and then penetrate through
the gathering film of misanthropy, prompt a benevolent view of human
nature and make my reader more in good humor with his fellow-beings and
himself, surely, surely, then, I shall have not written in vain."
SOME OF THE THINGS NECESSARY TO THE ERADICA-
TION OF TUBERCULOSIS.
Dr. J. E. Brooks^ Blowing Rock.
The days of secrecy and mysticism in medicine are gone. The doors are
now thrown wide open, and all men are invited to come in, see for them-
selves, examine our work, put it to the test, and decide for themselves its
worth. We have approached a new stage, live on a higher plane and invite
constructive criticism. We are applying our knowledge to the common
good, and giving without the asking the fruits of our investigation to the
general welfare. We know we are at the dawn of a new era. A world-
wide age is upon us. Universal democracy is thrust in. The destiny of
man is the chiefest concern of the doctor, and those who assay to lead must
be capable, without spot or blemish, and worthy of the golden day that
awaits us. The great doctor will heed the call, and the small one must
We have no time to lower our ideals or to gather gear, because our work
deals without limit or class with every creature under the sun. The doctor
may not be a benefactor to begin with, but his work leads to that destiny
if he pursues it free from fraud and guile. The new age in medicine has
not yet seen wide experience or effected a good working organization, but
the results obtained by it are so vast and promising that no man whose eyes
are open can dispute its worth or work. I confess no liking for the apothe-
cary shop — but there is a divine thrill in getting there ahead of the proces-
sion. In preventing disease you plant a rose instead of inurning ashes. . . .
The new open door of co-operation of the profession and the public does
not aim to make practitioners of the laity. It means to educate the laity to
co-operate with the doctor and bear him up in every f:;ood word and i^-ork
Nor does it mean the loosening of its hard rules to the quack and vendor,
but it does mean to cut off the quack's head through education. It means
to give to the public sufficient scientific knowledge concerning contagion to
secure his help in eradicating disease. Blackstone wrote his Common Law
232 NORTH CAROLINA MEDICAL SOCIETY
for the gentry of England that better citizens might result therefrom. After
the beginning of the world war Sir William Osier chided England be-
cause its ruling classes, though graduates of Eton and Oxford, knew too
little science to be capable of their work. He ■:ited as witness the fact that
the Minister of Foreign Affairs, when called down for allowing hog lard
to be shipped to Germany, confessed he did not know that glycerine, one
of the chief sources of explosives, could be derived from hog lard. Dr.
Osier demanded that England teach all of her men the rudiments of science
as a necessity.
For years I have read with interest the current literature on public health
and preventive medicine ; and the accomplishmnets along these lines are
so fine that men thought them impossible. The sanitary work of General
Gorgas at Panama enabled the United States to build the Panama canal
— a thing which the world-renowned engineer. Count Ferdenan De-Lessips,
could not do because the enemy, disease, was stronger than his skill as an
engineer. The fight against yellow fever, typhoid and cholera are almost
won, and the fangs have been extracted from diphtheria and smallpox, while
a great war is being waged against tuberculosis- And brilliant addresses,
illustrated until the eye can see, are being delivered daily. These shows and
addresses have amazed and thrilled the public mind. Edwin Booth could
entertain no more brilliantly in impersonating Hamlet than a brilliant lec-
turer, well equipped with illustrations, can do with an up-to-date address
on public health. A thousand times have I been asked to explain phases
of these writings and addresses by those who saw and heard them. And
it is indeed an impossible task for me to make intelligible a subject when
the questioner has no scientific knowledge upon which my explanation must
rest. I answer his questions, but I leave him without understanding. These
lectures, though as good as they can be made, cannot enlighten me on a
subject that requires some science as a basis for such enlightenment. The
public must understand before it volunteers its whole-hearted co-operation.
None of us believe anything we have no way of understanding.
The public is inviting us to go deeper into the subject than we have ever
gone- It is placing its children at our disposal ; and it is through the coming
generations that Providence is showing us the way. Through the public
schools the future problems of public health and preventive medicine must
be solved. I do not believe j^ou can make a man all-around fit by making
laws to make him whole. You must lead him and show him the way. Let
us be reminded that in a few short years the world in miniature will be in
school. If the parents or guardians are indifferent, the State is not going
to be a slacker with its own life — and the State must educate to save its life.
In the schools will be laid the foundation to fight all contagion and make
the term prevention a reality. Out of all the expense, the suffering and
tragedy and death and victory of the world war comes one word clear above
all else, a word that will be the watchword of civilization in the unnumbered
generations to come, and that word is 'TITNESS." Physical fitness is the
basis of mental and moral fitness, and there can be no absolute fitness that
does not qualify the man and woman to think normally, possess normal
health and a sound moral character. I believe that a majority of the weak-
nesses human flesh is heir to are traceable to physical unfitness.
PUBLIC HEALTH AND EDUCATION 233
The doctor of medicine gives his life to the study of life, and by virtue
of his work becomes a biologist. We all know that mediocraty as rule
biology applies to man, with the great and powerful the exception ; and of
these exceptions no known law governs their advent and no one knows from
whence they come. Shall the doctor use his biology to no higher purpose
than the pasting together of broken pottery? Would it not be better that
he use his science to remove the cause of this order so that the great and
powerful wnll be the rule, and the weaklings the exception. Indeed, we do
produce numberless intellectuals and geniuses of varied kinds, but it is only
the few who are touched by greatness, and though widely separated, they
are generally contemporaries in periods far apart.
EDUCATION.
The hour is at hand when the doctor must begin the work in the school-
room. This will reach the world in a score of years. The rudiments of
physiology taught in the public schools taught phj'siology to no one, but
the simply and beautifully illustrated chapter on the baneful effects of
alcohol on the human system had far greater results in driving alcohol out
of America than did all the bread-counter oratory of the world. Let the
Medical Society of North Carolina, with the State Board of Health, ap-
point a committee to collaborate and formulate a manual of preventive
medicine and public health and embrace concrete primary information of
contagious, infectious and communicable diseases, their causes, modes of
conveyance and transmission. It should contain the information the laity
must have before the public can give the doctor a whole-hearted helping
hand in prevention. This treatise should be one that can be used from
the fifth to the seventh grades, and made a part of these grades. Of course,
the committee would decide the nature and thoroughness of the text. It
must be made clear and understandable to every student capable of passing
the seventh grade. The public teachers must prepare themscives to teacn
this text. The colleges and normal schools must give them these courses,
and the course must be more complete for the high school and college. This,
when properly put in operation, cannot fail to produce world-wide results.
Gentlemen, when we begin with this method of fighting communicable
disease we begin a revolution in public health work that can never look
back, and by this method tuberculosis will be made a rare disease indeed.
I approve of the great work of the Sanatorium, but the Sanatorium gets
many a patient when he is too sick to be taught or when the work on him
is but patchwork. I am fully aware that the Sanatorium has done vast
good. Now let us go to the root of the evil and cut it out.
THE NEGRO.
Has anybody in our state done anything to prevent the dissemination
of tuberculosis in the negroes among themselves, and from them to the
whites? Does anybody have any idea what percentage of the negro race
What provision has been made to treat the negro patient when his case is
pronounced tuberculosis? Can we accomplish any serious results among
the whites until like results have been accomplished among the negroes?
Can you prevent flies swarming ar.ound the mansion of the rich man while
his neighbor's filthy hut is a breeding place for them? Does not sanitation
234 NORTH CAROLINA MEDICAL SOCIETY
itself mean complete sanitation, Why not use the incipient tubercular
patients, and there are many of them, among the negro convicts of the state,
to build a sanatorium and develop a farm for the tubercular patients of
that race ? And may I not add that it might be a good thing if the incipient
tubercular patients among the white convicts be employed to develop and
cultivate the farm at Montrose for that institution ? While their recovery
is directed by that institution.
Discussion.
Dr. Frazer, Asheville : I think there could be no question as to shortage
of Sanatorium in this state. We have begun to wake the doctors up to the
necessity of taking care of these cases.
We realize it is a chronic infection. In my opinion, it is a large economic
disease. I am suprised that this was not brought out more in the papers.
We know that infection takes place and that all the education we may give
the child is very valuable, but it will not prevent the infection that has taken
place. We cannot always cope with the condition that the patient arrives
at when he becomes of age or takes his place in the work of the world. We
will say with long hours, or hard work and not enough food that the patient
loses his resistance and becomes incipient tuberculosis.
Dr. Brooks spoke of the negro, and I think that is going to deserve con-
siderable attention- We have been regarding them as doomed. We felt
that no matter what we did for them, in the end the result was the same.
I saw recently the report of the Maryland Tuberculosis Association, that
the negro had made about four-fifths of the progress in the Tuberculosis
Sanatorium at Maryland compared to the white man. It is not quite fair .
to compare the death rate of negroes to the whites. When we say that eight
negroes died to four whites of Tuberculosis we might think that is the racial
trait. The negro is by no means given a fair chance. The recent teachings
have shown that if we give the negro a chance he will get well.
The establishment of a sanatorium for the treatment of patients privately,
while we may get great results in the near future, it does not mean that
that patient is cured, that was followed by the word "arrest." We may
say "arrest-ed." It is going to take not only Sanatorium Treatment, but
after-care for months and years until we can decide that the patient is cured.
Dr. R. McBrayer, Sanatorium: In answer to Dr. Brooks' question as to
what is now being done for the negro, I would like to say the State Tuber-
culosis Association is running a truck, with motion pictures that is carrying
its films on Tuberculosis, the Modern Health Crusader, the Public Health
Nurse, Oral Hygiene, etc. This car goes to the county and is under super-
vision of the Public Health Instructor — he is in Mecklenburg this week.
The negroes are taking much interest in this, and it is going to give excellent
results. I think his point was well taken when he said we can't stop infec-
tion in the white people when we have that infection living at the back door.
We don't notice the negro much when he gives a little cough, but we should-
However, I think that is a very important problem from now on, and we
probably have been a little negligent about it up until now.
Dr. Carlton, Winston-Salem: I would like to say in addition to what
Dr. McBrayer has said in defense of my own health department. We have
PUBLIC HEALTH AND EDUCATION 235
a dispensary in our citJ^for white and colored, and in our hospital for tuber-
culosis we have as many beds for colored as white and as many treatments
among colored children as white.
Dr. Stevens: I would like to say a few words as regards the negro. It
is a well known fact to all of us that the virulence of bacteria vary. One
condition is passing bacteria through an animal that offers low resisting
power. As has been said here, the negro as a race offers lower resisting
power to the growth of tubercle bacillus. The negro being infected with
tuberculosis develops a more virulent type of the disease. Any negro in-
fected with it is a greater possibility of danger to others than from any
one else infected with it. An infection from him is apt to be a very acute
type of infection. Protecting the negro is a very important question of
protecting the white race also.
Dr. Anderson, Raleigh : I want to endorse this paper of Dr. Brooks on
one point, and I am glad to hear a man of his information and work stress
the point of education, of management and prevention of tuberculosis. I
feel in my own work rather pessimistic at times, because of the lack of in-
formation and education in the prevention of the mental diseases- I have
gotten so much information that I feel inspired to be more hopeful in my
special line of work from the work you folks are doing in the public health
work.
I am reminded more and more of what we lack in the prevention and
real education along the lines of mental diseases. If you look at it right,
the mind is really more important to keep well than the body, and as our
Governor expressed it some time ago, that we have the cart before the horse,
and therefore the importance of education as Dr. Brooks emphasized. We
have to go on in the school room and educate our children on this subject
of disease prevention, whether physical or mental- When we come to think
of the educational forces that we have in North Carolina, if I understand
it right, it makes a man feel pessimistic. They tell me those school houses
are occupied or frequently occupied by incompetent workers. That
talk that the lady made from Randolph county yesterday was the best thing
I have heard in a long time. If we could get a few workers in North Caro-
lina to handle diseases of the body and mind, it wouldn't take us long to
educate the people in the right direction. Education is the key-note, and
when we can get it into our schools and get these things handled by compe-
tent school teachers, then a brighter day is coming.
Dr. Edwards: I want to say that I hope to see the time in the nea/r
future when we will have ample facilities for taking care of tuberculosis.
That we will have room at the State Institutions for both colored and white
patients, and that in the South we will have separate institutions. I think
in the very near future we will have such.
Closing Discussion, Dr. Brooks: I think if you will ask any man who
has ever done any tuberculosis work he will tell you his greatest difficulty
is establishing an intelligent understanding between himself and the patient.
It does not matter if this patient is a lawyer capable of becoming a Supreme
Court Judge, even down to the illiterate. You talk to him in a foreign
language and he goes away from you without understanding the basis upon
which fear and knowledge rests. This has been my experience, and a very
236 NORTH CAROLINA MEDICAL SOCIETY
painful experience. At 4:imes it would seem that we get brilliant results.
We flatter ourselves that we have a patient we are going to restore, and
in that time he gets away from us. He does not like these fundamental
principles of science. It must be taught to the children in the school-
room. I insist that this scientific information about communicable dis-
eases must be a part of your child's course. He must study this as he
studies grammar and English. He is supposed to get something of the
nature of a disease, and something of its prevention and what his part of
prevention must be, and you can't ever get him to understand that or
follow it until you teach it to him. I have failed in my patients, and
many times I have felt I was a failure all over, because I couldn't achieve
anything except that my fellow-servant was doing it all, and if I dropped
out he could do it far better than I ; but he was doing nothing but patch-
work. His work is constructive, and he must teach the race how to be
strong, and he cannot do that until there is a line of communication between
him and that race, because that race cannot know what he is talking
about, and does not know.
I have gone away many times from a patient feeling that I was utterly
helpless. I could not control that patient, and no one else could, because
he could not talk with him. Let the school rooms teach the rudiments
of science.
VENEREAL DISEASES— A PUBLIC PROBLEM.
The Physician's Responsibility for Their Control.
By Millard Knowlton, M. D., C. P. H.,
Director Bureau of Venereal Diseases, N. C. State Board of Helath.
THE PROBLEM.
A sense of public responsibility for the venereal disease problem is one
of the by-products of the war. When faced with the necessity of utiliz-
ing the manpower of the nation to the limit in combat with a first-class
military power, America soon recognized venereal disease as the most
serious communicable disease menace to its military strength. Medical
men have not forgotten that 5.4 per cent of the second million men called
to arms had venereal disease when they reached camp. Thus the war
brought the venereal disease problem to the front as a public problem.
Even in war time the venereal disease problem is essentially and funda-
mentally a civilian health problem. Five out of six of the soldiers suffer-
ing from venereal diseases were infected before enlistment- The others
became infected by contact with the civilian population. Adequate
preparation for the defense of the nation against future aggression requires
careful attention to the venereal disease problem by the civilian com-
munities. Any problem so closely related to the defense of the nation
is a public problem.
Inasmuch as gonorrhea is looked upon as the greatest sterilizer, and
syphilis as the greatest abortifacient, it behooves the people to take
measures against the ravages of these diseases in order to maintain the birth
rate that will give the best assurance for the future of the nation. An ex-
cess of births over deaths is necessary if a nation is to grow strong. France
PUBLIC HEALTH AND EDUCATION 237
is now suffering because of a low birth rate. Any factor that affects the
birth rate as does venereal disease is a vital public problem.
During the war it was found that in a large munition plant employing
10,000 workmen, 68 per cent of the workers on the non-effective list each
day were listed because of venereal diseases. Production among those so
infected was found to be 33 per cent below normal. Facilities for treat-
ment were provided, and 2,000 employees were treated during the year.
Every man's output returned to normal after treatment was concluded
and the man returned to health. The company estimated that the work
was worth at least $150,000 per year in increased production. At this
time of high prices whatever tends to retard production is a public problem.
Another factor of immediate public concern because it involves the ex-
penditure of public funds is the relation of venereal diseases to dependency
and defectiveness. How much of the State and local expenditures for the
care and maintenance of dependents and defectives have been made neces-
sary by venereal disease cannot be said. That such expenditure is far
beyond the cost of prevention must be apparent to anyone w^ho will give
the matter a second thought. Indeed, when we consider the public charges
in the alms houses and other institutions whose lameness, epilepsy, blind-
ness, feeble-mindedness, insanity or other cause of dependency is due to
venereal disease, we may well believe that the State would profit by taking
measures to prevent these diseases, as did the munition plant, by providing
treatment for infected persons. Thus it appears that when viewed from
any angle the venereal disease problem is a public problem. Even from a
clinical point of view, pay for the treatment of such diseases among the
indigents must come from the public purse.
THE REMEDY.
Owing to the complicated and intricate character of the venereal disease
problem, the remedy has not been one of easy attainment. Experience has
led to the direction of the campaign against venereal diseases along three
general lines:
1. Educational measures for the dissemination of information are re-
garded as fundamental for any kind of advancement under a popular form
of government.
2. It is now almost universally recognized that effective measures against
venereal diseases will include the repression of prostitution, which is the
great source of infection. Prostitution is no longer to be regarded as a
fixed part of the social structure or even as a "necessary" evil. As a com-
mercialized institution its doom is sealed. The public will not permit a
return to the old conditions.
3. That part of the attack against venereal diseases which is of most
interest to physicians is treatment. It is by proper treatment that infected
persons are rendered non-infectious. Thus, treatment is a matter of public
concern and the physician who properly treats a case of venereal disease
performs an important public service.
So much by way of introduction. I wish to use the rest of the time
allotted to this paper in a discussion of the problem of treatment. I have
no information or suggestions to offer concerning the methods of treatment.
238 NORTH CAROLINA MEDICAL SOCIETY
I wish merely to make a plea for better treatment, and to suggest a plan
whereby I believe that better treatment may be provided for patients in
remote communities.
THE physician's RESPONSIBILITY.
No one but a physician is qualified to properly treat venereal diseases.
This is one branch of the healing art in which physicians have the monop-
oly. The osteopath, the chiropractor and the Christian scientist are con-
strained to withdraw from the field and leave the medical man in full con-
trol. This monopoly pre-supposes a responsibility and a better preparation
for the discharge of their full duties that I now wish to plead with the
physicians of North Carolina.
Medical men are disposed to take venereal diseases somewhat more seri-
ously than formerly, but many physicians still do not care to treat such
cases. To be sure, there are unpleasant features about this work; but the
physician's responsibility cannot be fully discharged by giving indififerent
or careless treatment. The physician owes it to both his patient and the
public to see that the best possible treatment is given.
All physicians will agree that patients should not attempt to treat them-
selves and should not rely upon drug-store treatment or treatment by quacks.
In our propaganda designed to turn patients away from self-treatment, the
counter-prescriber, and the quack, it is constantly urged that proper treat-
ment can be given only by a qualified physician who can examine the patient
carefully in order to determine what treatment is needed. Sometimes the
busy doctor makes an unfavorable impression upon the patient by failure
to live up to our promises concerning a careful examination. A case in
point is that of a North Carolina woman who was infected with gonorrhea
by her husband upon his return from the army. Before treatment was com-
pleted it became necessary for her to move to another city, where she sought
to continue treatment under a physician's care. Her experiences in that
connection are given in the following extracts from a letter recently received
in our office:
"I have tried three doctors, and the one who was most recommended,
Dr. , merely asked me what treatment the doctor in had
given me, and told me to continue that treatment. He did not sjiy for how
long, nor did he offer to make an examination. According to your pamphlet
and letter such indifferent advice is unsatisfactory- This doctor did not even
ask me to come to see him again. He acted as if he were wholly incompe-
tent to give advice in this case."
"I am very much concerned about my condition, and I want to be helped.
I have already spent a large sum of money for medicines, doctors' advice,
etc., and a great deal of time in treating myself, and I think I am entitled
to some results for my outlay of time and money. Why cannot the law
require doctors to be more competent? I think any doctor as negligent
as the one I have mentioned should be reportable by the patient. A case
like this is too serious for a doctor to be careless about."
The foregoing statement by a woman of education and refinement merits
serious consideration by physicians. If the medical profession is to maintain
its prestige with the people and continue to enjoy the fullest public confi-
PUBLIC HEALTH AND EDUCATION 239
dence, it is highly important that physicians meet the increasing demands
of a more fully educated public.
In meeting these requirements only two courses are open to a physisian
when a venereal disease patient applies for treatment. These are either to
give the best possible treatment himself or refer the patient to a physician
who will give the best possible treatment according to modern methods.
Remembering that each uncured case of venereal disease is a source of dan-
ger to others, the physician can perform his full duty to himself, his patient,
and the public only by pursuing one or the other of these courses.
The public interest requires that all patients suffering from venereal
disease be properly treated, no matetr what their, race, color, or social posi-
tiori may be. Venereal diseases, like other communicable diseases, know no
racial boundaries. Where different races of mankind are intermingled
It is to the interest of each race as a matter of racial self-preservation if
from no higher motive to have venereal diseases properly treated in mem-
bers of the other race. The physicians of North Carolina have it within
their power to see that proper treatment is given to all citizens of the State
suffering from venereal disease.
I am not asking physicians to work without remuneration. Most venereal
patients can afford to pay at least a reasonable fee for treatment. In the
few instances where a person suffering from venereal disease in communi-
cable form is really indigent, it is simply a matter of self-protection for a
community to provide treatment at public expense. The State Board of
Health will provide arsphenamine free for the treatment of indigent syphil-
itics who are infectious, provided the community or a big-hearted doctor
will see that the drug is properly administered- In the larger communities
the most convenient way of providing treatment at public expense is by
means of clinics. In the smaller communities some modification of the
clinic arrangement may be necessary.
I have urged that each physician either give the best possible treatment
or refer his cases. Perhaps you are asking to whom the cases maybe re-
ferred. It is realized, of course, that only the larger cities can support
specialists. As North Carolina is a rural state, only a small percentage of
its population live in or near the larger cities.
To the end that rural medical service may be improved, it is proposed
that the medical men of each community provide at least partial specializa-
tion in medical service to that community. This will be possible through
concerted action. As a first step, let the physicians in each county get*
together, talk over the proposition and select from their number one who
is willing to make special preparation by study and equipment for the proper
treatment of venereal diseases. Of course, he cannot hope to limit his prac-
tice to this line in a small community, but by partial specialization he can
become an authority on the matter for his own community to whom patients
may be referred or who may be called in consultation in difficult cases. The
man who thus qualifies himself for the better treatment of venereal diseases
should be selected by the board of county commissioners to treat indigent
patients. He should be recognized by the medical profession of the com.
munity in such measure as to make worth while his expenditures in time
and money for special training and equipment.
240 NORTH CAROLINA MEDICAL SOCIETY
The plan here proposed would result in advantage to both the medical
profession and the public. Thus it would accord with a principle that is
now happily appearing more clearly in the vision of far-seeing medical men.
This principle is that the ultimate interests of the medical profession are
parallel to the best interests of the public in medical matters. While recog-
nizing the fact that public interests are paramount to those of any class or
group, medical men will do well to remember that the doctor serves himself
best by serving others.
The gist of the whole matter is that the level of medical practice with
respect to the treatment of venereal diseases should be raised to as high a
point as possible in all communities of the State. This requires a specializa-
tion which comes as a natural process in larger communities. In smaller
communities the same end can be reached in lesser degree perhaps by a pro-
cess of partial specialization encouraged and stimulated by the medical pro-
fession. It falls to the lot of medical men to prevent the spread ^f venereal
diseases by the proper treatment of existing cases. For the best results
united co-operative efforts for encouraging specialization are required
Here I beg to leave the matter in the hands of the medical men of North
Carolina, in full confidence that they will rise to the opportunity for public
service and take active measures to provide better treatment for venereal
iisease cases in all parts of this State- Let me urge again that united effort
ind co-operation are necessary. If we doctors do not hang together, the
public may give us a chance to hang separately.
THE STATE PROGRAM FOR VENEREAL DISEASE CONTROL
By Millard Knowlton, M. D., C. P. H.
Director Bureau of Venereal Diseases, N. C. State Board of Health.
The venereal disease campaign that has been pushed so vigorously for
the past two years has been an experimental excursion into an unexplored
realm. Prodded by war recessity, the country and the various states have
undertaken to follow the vision of a few forward-looking men. The course
has led through bramble and thicket, and we are not yet out of the woods,
but slowly some of the fundamental things nre emcrgmg from the chaotic
thought surrounding the subject.
Before the war, efforts for venereal disease control were spasmodic and
intermittent. Here .^nd there health authorities feebly called upon doctors
to report their cases by number, and a few state legislatures were beginning-
to -consider measures dealing with the problem. The chief energies
focused on the subject had been expended in propaganda by a few voluntary
organizations. Thus, while the preliminary work of gathering and dis-
seminating information and formulating speculative and theoretical plans
had been under way for some time, there had been little practical experience
in applying such plans to the actual problem of venereal disease control.
Accordingly, those of us who plunged into venereal disease work on a
wave of war enthusiasm found a field unknown, to be cultivated by methods
untried. In proceeding from the known to the unknown, it was but natural
that the course adopted should be analogous to that pursued in the preven-
tion of other communicable diseases- Experience soon demonstrated, how-
ever, that there were certain fundamental differences between venereal
diseases and other communicable diseases that must be taken into account.
PUBLIC HEALTH AND EDUCATION 241
In the first place, all cases of venereal disease are not in communicable
form, and, therefore, all cases are not subject to control by administrative
procedure of a health officer. Thus, a case of syphilis of the central
nervous system may give a positive Wassermann of both blood and spinal
fluid yet not be a case to come under the jurisdiction of a health officer,
for the reason that evidence cannot be produced to show that it is possible
for such a patient to convey the disease to others. From a public health
point of view it is necessary to make a clear distinction between a case that
is infectious and a case that is not infectious. The health officer is interested
in a case only so long as it is infectious and capable of transmitting infec-
tion to others It is the health officer's business to prevent such transmis-.
sion of infection. However much need there may be for a continuation of
treatment until a clinical cure is effected, the health officer is officially
concerned with treatment only until the patient becomes non-infectious.
In making an examination of a patient to determine whether or not such
patient is a menace to the public health, the health officer must determine
two things: First, the presence of venereal disease! and, second, whether
or not the disease is present in communicable form. Action to protect the
public health is based on the presence of disease in communicable form
and not en the presence of disease per se.
Another and still more important difference between venereal diseases
and other communicable diseases is that in the case of venereal diseases not
all patients suffering from such diseases in communicable form are menaces
to the public health. In fact, very few patients will endanger the public
health if properly instructed in methods of prevention unless, as in some
instances, their occupations are such as will endanger others by the ordinary
contact of daily life. Whether or not such a patient is a menace to the
public health depends ordinarily upon his sex conduct. This introduces a
factor which makes the venereal disease problem at once the most compli-
cated, the most difficult, the most intricate and in some respects the most
important of all the public health problems.
The bearing of these differences between venereal diseases and other
communicable disease upon administrative measures to be taken for the pro-
tection of the public health is apparent upon a moment's reflection. Obvi-
ously, those cases that most concern the health officer are those that are
most dangerous to the public health. Thus reporting regulations that will
result in having brought to the health officer's attention only those cases
of venereal disease that are dangerous to the public health will save his
time in the investigation of non-infectious cases. If such regulations can
be made to serve as a filter to catch only infectious cases, the public health
will be protected as well as if the health officer had to examine all patients
suffering from these diseases. This end is attained by permitting the phy-
sician to report patients not dangerous to the public health by number Avith-
out disclosure of names, and requiring the name and address to be reported
only in case the physician thinks the patient should come under a health
officer's supervision for the protection of the public against his infection.
Reports by number are as useful for statistical purposes as reports by name.
Likewise, the invoking of quarantine as a measure to protect the public
242 NORTH CAROLINA MEDICAL SOCIETY
health will depend upon conditions outside the existence of venereal disease.
In the majority of cases quarantine will not be required- Only in those
cases that cannot be trusted to so conduct themselves as to avoid exposing
others to infection will restrictive measures be necessary.
On account of the very complex factors involved, the method of carry-
ing out quarantine procedure in venereal diseases must of necessity be
■different from the method of carrying out such procedure in other com-
municable diseases. In scarlet fever, for example, every case is a menace
to the public health, and, therefore, all cases are equally subject to quar-
antine. In such cases, quarantine can be carried out by isolation in the
home. Most people wish to do the square thing, and the opinion of the
neighbors is a powerful factor in preventing attempts to evade quarantine
regulations when the house is placarded. In the case of venereal diseases,
however, law-abiding, responsible citizens who have had the misfortune
to become infected may be trusted to avoid spreading the disease to others
if they are properly instructed. Accordingly restrictive measures to pro-
tect the public health may with safety be limited to those who would not
carry out instructions, and who could not be trusted to avoid exposing
others to infection while under treatment. Chief among this group of
irresponsible people are the pimps and prostitutes. In applying quarantine
to such characters isolation in the home has not been found to be effective
Forcible detention is necessary for the adequate protection of the public
health. It is for this reason that the law authorizes quarantine in jail if
no other suitable place for quarantine is available.
So much for the rather technical public health side of the problem.
There are other aspects of the problem in its larger relations that extend
beyond the field of public health, and interlock with the duties of other
officials and functions of other departments of government. While the
treatment of existing cases is now recognized as a primary necessity in
order to render them non-infectious, and thus not dangerous to the public
health, it is clearly seen that treatment alone without taking steps to stop
the source of supply is a good deal like the building of a hospital at the
base of a clil5 to care for those who fall over instead of building a fence
at the top to prevent them from falling. In the one case the hospital is a
humane measure of cure, but it is more expensive and less effective than
the fence as a measure of prevention. In the other, the necessity for treat-
ment to render patients non-infectious would be greatly lessened by effective
measures for the repression of prostitution, which is the source from which
venereal disease is obtained and passed on to innocent victims. The re-
pression of prostitution is primarily the duty of peace officer and court
officials, but the law recognizes the relation of prostitution to the spread
of venereal disease by requiring health officers to co-operate with other
officials in performing this function. Such a broadening of duties greatly
extends the horizon of the health officer and requires him to recognize and
grapple with social problems as never before.
Of special importance in the promotion of any movement requiring
public support in a popular government are those activities concerned with
the dissemination of information usually designated as educational work.
In the venereal disease campaign educational work is particularly difficult
PUBLIC HEALTH AND EDUCATION 243
owing to the relation of venereal diseases to sex conduct and the delicacy
of the questions involved. Here again the things that must be done extend
beyond the field of public health, this time into that of the school. In-
struction concerning the contribution that sex makes to life and the physi-
ology and hygiene of reproduction is distinctly an educational activity
rather than a health activity. The health authorities are taking the initia-
tive in this work because the educational authorities are not yet equipped
to do so. The kind of educational work concerning this subject that belongs
definitely to the health authorities is instruction concerning the ravages of
venereal disease, and the methods of cure, prevention and control. When
the period of experimentation is over and the functions of the different
branches of government with reference to this problem are more perfectly
adjusted, the educational work will be divided between the health authori-
ties along these general lines.
The provision of recreational facilities as a preventive measure against
venereal disease is mentioned here merely for the sake of completeness.
While this line of work is important, it is not a health department function.
Thus, the huge, country-wide experiment that has been carried on for
the last two or three years, has resulted in fixing certain definite lines of
activity as fundamental to any complete program of venereal disease con-
trol. These may be enumerated as follows :
1. Treatment of existing cases to render them non-infectious.
2. Administrative measures of control by the health officer.
3. The repression of prostitution, for the purpose of cutting off the
supply of infection.
4. Educational measures directed toward giving higher standards of
sex conduct and disseminating information concerning the ravages and
prevention of venereal disease.
These, then, are the principles underlying venereal disease control. In
carrying out this program in North Carolina, clinics for treatment have
been established in nearly all the larger cities and an active campaign is
now being conducted among physicians to stimulate interest in the better
treatment of venereal diseases.
The educational work is being developed along approved lines by means
of lectures, exhibits, motion pictures and an extensive distribution of
pamphlets. Lectures are arranged for men and women separately, and the
work includes a special educational campaign among negroes by a colored
physician. More than a quarter of a million pamphlets have already been
distributed.
The repression of prostitution by officials of local communities has been
encouraged through the collection and presentation of information con-
cerning vice conditions. Responsibility for this line of work has recently
been taken over by the Inter-Departmental Social Hygiene Board, who
are furnishing personnel for a division of protective social measures that
will soon be functioning.
The final working out of the program of venereal disease control will
include administrative procedures for handling individual cases dangerous
to the public health. Among these procedures will be that of quarantine.
244 NORTH CAROLINA MEDICAL SOCIETY
for which ample powers have been granted health officers by the Legisla-
ture. The Supreme Courts of the States of California, Iowa, Kansas,
Nebraska, Texas and Washington have sustained laws or regulations
conferring powers of quarantine for venereal disease upon health officers.
There have been no adverse decisions. Quarantine for venereal disease is
thus placed on a sound legal basis. A health officer's order of quarantine
is not subject to judicial review, unless fraud or bad faith is alleged. A
person held under quarantine cannot be released on bail. Thus a health
officer has more power than a judge of the court.
The greater the power the greater the dignity of the office. When the
public comes to realize that such great powers are vested in health officers,
the health officer will be given greater public recognition and appreciation.
If the power vested in an officer be considered as indicating the importance
of the office, then the whole cause of public health will be advanced
by gaining such public recognition through exercise of the quarantine
power.
AN IDEAL VENEREAL DISEASE CLINIC ORGANIZATION.
By Raymond Thompson, M. D-,
Of the Crowell Urological Clinic, Charlotte, N. C.
It is the aim and purpose of the venereal disease clinic organization to
reduce the prevalence of the venereal diseases as much and as rapidly as
possible by the detection and treatment of all carriers not otherwise under
treatment. There must therefore be a thorough campaign of medical treat-
ment, combined with the application of all measures that experience has
shown to be helpful, such as education, law enforcement, follow up work,
etc.
1. Organization of Clinic: It is the purpose of the United States Gov-
ernment, State and County authorities, to establish venereal disease clinics,
not only to treat patients who are infected, but to inform the people of the
seriousness of these diseases and prevent as far as possible the infection
being transmitted to other persons. The clinic should have the undivided
support of the local board of health, local medical profession, city officials,
Chamber of Commerce, the press, religious bodies, druggists, and all other
organizations interested in public health and social hygiene, /Jterature
prepared by the United States Public Health Service regarding sex diseases,
and how to obtain proper treatment, should be freely distributed. Stricf
di.^cipline s)iouM be niaintained among the Per-Jonnel and Clinic. The
officers should not forget the advantage in promoting a hopeful and inspip
ing atmosphere in connection with the scientific treatment of venereal
diseases.
2. Staff or Personnel: Two physicians, one female nurse, one male
nurse, one female social worker, one clerk.
The physician should be well trained in this special work. One physi-
cian should be the director of the Clinic, and the other the assistant director.
The physicians should direct the diagnosis and treatment of all cases, as
well as the general management of the Clinic.
The female nurse should assist at the examination and treatment of
PUBLIC HEALTH AND EDUCATION 245
female patients. After thorough instruction she may give the simpler
treatments.
The male nurse or attendant should assist with the examination and
treatment of male patients.
The social worker should see the patients on their first or second visit
and investigate their social relations and home conditions. It will be her
duty to bring in members of the patient's family who might be infected.
The clerk should keep a complete and accurate record of all the cases
and work connected with the clinic.
Follow up Staff: One of the greatest aids to the Venereal Disease
Clinic is a well organized follow up system. The social worker should
have charge of this department. The female nurse and male attendant
should assist in locating patients who fail to return for treatment. The
nurse will have the advantage of having seen the patients in the Clinic and
will be capable of impressing on them the importance of taking treatment.
Location: The Clinic should be convenient and easily accessible in loca-
tion. There should be not less than four rooms. It is necessary to have
separate waiting rooms for male and female patients. The races should
be separated or not — according to local customs. It is best to have separate
treatment rooms for gonorrhea and syphilis.
Equipment: The equipment recommended by the United States Public
Health Service is as follows:
1 operating table.
1 to 4 cheap wooden treatment tables.
1 instrument cabinet.
2 two-piede sterilizing outfit.
2 waste receptacle buckets.
1 office treatment stand-
1 Salvarsan outfit, with two 250cc glass containers, rubber tubing.
2 two-way stop cocks.
2 300 cc glass-stoppered mixing cylinders, graduated.
1 dozen Schreiber thumb needles.
1 Record syringe, 5cc.
6 Record syringes. Ice.
3 Record syringes, 2cc.
2 dozen 154-inch No. 21 steel needles.
1 bandage scissors.
3 knives.
6 haemostats.
2 pair scissors.
2 pair tissue forceps.
1 needle holder.
1 dozen assorted needles, catgut, silk, etc,
3 dozen finger cots.
1 dozen pair rubber gloves.
1 Janet syringe, lOOcc.
1 dozen olivary bougies.
1 dozen French olivary bougies.
246 NORTH CAROLINA MEDICAL SOCIETY
1 dozen Porgas olivary bougies.
6 filiform bougies.
6 filiform bougies, whalebone.
1 dozen Gonley's bougies.
1 Valentine irrigator.
1 Keyes-Ultzmann urethral syringe.
6 Fowler sounds.
12 Van Buren sounds.
6 female catheters.
1 dozen assorted rubber catheters.
1 Dickinson female double flow catheter.
1 cysto-urethroscope.
1 urethroscope.
1 Jollman dilator.
1 vaginal speculum.
1 uterine forceps.
6 sediment glasses.
1 Bausch & Lomb microscope, with Nos. 1-3, 1-6 and 1-12 lenses.
1 Bausch & Lomb dark field illuminator (full equipment, with two extra
boxes of carbon).
10 dozen lOOcc bottles-
10 dozen 180cc bottles.
2 pounds corks.
3 glass rods.
2 basins with covers for sterilizing purposes.
1 Bunsen burner.
5 feet rubber hose.
500 test tubes, regular size.
3000 wooden tongue depressors.
2000 wooden applicators.
3 card-index system :
A — Patients by name and number,
B — Patients by dates and names,
C — Patients by diagnosis and number.
History cards.
1 platinum loop.
1 dozen 2-liter flasks.
1 dozen 1 -liter flasks.
10 pounds hydrogen peroxide.
5 pounds phenol.
5 gallons alcohol.
2 pounds potassium permanganate.
5000 formin tablets, 5 gr.
1 pound iodine crystals.
5 pounds thymol iodid.
1 ounce silver nitrate.
1 pound calomel powder.
10 pounds 1 and 2-inch gauze bandages.
500 yards surgical gauze for dressings.
20 pounds sterile absorbent cotton.
PUBLIC HEALTH AND EDUCATION 247
10 gallons Mistura copaibae compositus, N. F.
2 pounds corrosive sublimate tablets.
2 pounds arg>Tol.
2 pounds protargol.
1000 glass slides.
1000 cover slips.
Cedar oil.
5 pounds mercury salicylate, 1-2 to 1 per cent in sterile liquid petroleum,
made up in lOOcc, wide mouth, shallow bottles.
50 pounds Unguentum hydrargarum, U. S. P., 50%.
1000 ointment boxes, 1 ounce.
Desirable additions:
High-pressure steam sterilizer,
Hot-air sterilizer,
Small incubator.
Clinical Hours: The clinic should be opened daily, except Sunday, for
as long a period as necessary to properly treat all cases. The female
patients can usually attend early afternoon hours best — three to five
o'clock ; male patients later hours — five to seven. Unless you have separate
waiting and treatment rooms it is better to have female patients come early
and male at a later hour. The Clinic should always open promptly at a
regular hour and close at a specified time.
Examination of Patients: The first examination should be made by a
physician, a complete history, clinical findings and routine laboratory tests
made and recorded- The patient should be treated "humanely" and given
intelligent information regarding the importance of proper treatment.
Records: Accurate records on forms provided for this purpose should
be kept of all cases. These records include history, symptoms, physical
signs, clinical findings, laboratory reports, special examinations, treatment
at each visit, and final results. Report of social worker, visiting nurse and
other reports dealing with the case should be recorded.
Laboratory: There should be a laboratory conveniently located, in com-
petent hands and fully equipped to make all desired examinations. The
bulk of laboratory work will consist of dark-field examinations, Wasser-
mann tests, smear examinations and urinalysis.
Regulations Regarding Standard Treatment: The clinic should follow
as nearly as possible the standard adopted by the U. S. P. H. S. and State
authorities.
Hospital Cases: It is necessary to make arrangements with a local hos-
pital for taking care of patients needing hospital treatment. There will
be a great many minor operations in addition to medical cases which re-
quire institutional care.
Management of Patient: If the phj'sicians will assume the attitude that
they are treating patients, with an infectious disease, and not outcasts, who
should be damned on account of having venereal disease, the patients will
feel that you are doing what is best for them and at least a great majority
will gladly return for treatment.
248 NORTH CAROLINA MEDICAL SOCIETY
THE IMPORTANCE OF LABORATORY FACILITIES FOR A
VENEREAL DISEASE CLINIC.
By Dr. L. C. Todd, Charlotte.
In the organization of the State Venereal Clinics under the direct super-
vision of the United States Public Health Service, the latter has emphasized
the need of the laboratory as an integral part of the local clinic. In the
case of the smaller clinics, whatever laboratory work that is done locally is
usually taken care of by the director or his assistant together with the
State Board of Health laboratory assisting by doing the serological work.
This will be accomplished by establishing necessary laboratory facilities
for doing a complete urinalysis, for examining smears and for making dark-
field examinations.
Where the number of cases cared for increases to such a point that the
medical workers are obliged to neglect even the simpler' laboratory pro-
cedures, a much larger volume of work of a more prompt and more accurate
nature will be accomplished by establishing the necessary laboratory facilities
in the hands of a qualified laboratory technician as a part of the organization.
The number of laboratory examinations can then be increased without
taking time from the examinations of new patients or from the case of
those already under treatment- Thus the clinical members of the staff
may be entirely released to devote their ^ time to their outlined work, and
they will not be tempted to forego the advantages of what the laboratory
has to offer in the way of a corroboration of their diagnosis or as a guide
to their treatment because they may be over-burdened with other work.
To be of most service to the clinician, the laboratory should be as con-
veniently located as possible, so that its function as a diagnostic aid may be
called into use without delay and its place as a guide to treatment may be
always filled.
Upon admission, the new patient's examination should include routinely
the collection of a blood specimen for the Wassermann test. Whether the
entrance examination reveals a clinical case of lues or not, this procedure
may add evidence to the clinical diagnosis and may frequently, in a clinic
of this nature especially, draw attention to the fact that the patient has a
latent luetic infection. Of the entrance blood Wassermarins of the last 1090
cases admitted to the local clinic, 482, or 44 per cent, were found to be
positive. Among the cases reported negative were many early primaries,
but among the positive cases were many coming to the clinic because of an
acute gonorrhoeal urethritis. Thus attention was drawn to a latent syphilitic
infection in the latter group.
All penile sores are to be examined particularly with the view of proving
whether or not the lesion is the initial site of a syphilitic infection. When
we recall that only about 36 per cent of blood Wassermanns are positive
by the end of the first week following the appearance of the chancre and
about 60 per cent are positive by the end of the second week, we are im-
pressed with the importance of using every effort to establish a diagnosis
by the earliest means at our command — i. e., the dark-field examiantion.
Repeated thorough dark-field examinations are made in search for the
spirochaeta pallida. No local applications except non-spirochaeticial moist
PUBLIC HEALTH AXD EDUCATION 249
dressings should be used until an earnest search has been made and the
absolute diagnosis arrived at or the quest abandoned. Only then should
active treatment be instituted. Every physician coming in contact with'
patients exhibiting penile sores or suspicious extragenital lesions should
consider it his bounden duty to arrive at a diagnosis as early as possible,
and especially before the positive blood Wassermann gives evidence of a
generalized infection. Before such generalization takes place treatment
more frequently results in a prompt cure. Failure to find the organism
has little value in proving the lesion non-syphilitic. Chancroid is so fre-
quently complicated with syphilis that a diagnosis of pure chancroid should
not be made until a fair attempt has been made to determine the presence
of syphilis. When the dark-field search is fruitless, weekly Wassermann
tests should be made for six weeks and treatment instituted immediately
if indicated — at the same time repeating the blood test to further corroborate
the positive finding.
Routine smears — urethral, cervical, vaginal, etc., are indicated on all
new admissions, chiefly for the establishment of the diagnosis, but also for
the observation of the stage of the disease and for the selection of the ap-
propriate treatment- Many syphilitic patients should also have an exam-
ination made of the prostatic secretion to discover the latent cases of gonor-
rhoea.
All patients to receiv'e arsphenamine should have a complete urinalysis
done at the commencement of their treatment, and their urine should be
examined for albumin and casts preceding each subsequent intravenous
injection — occasionally during their mercurial treatment and at such other
occasions as their signs and symptoms indicate. By this means there will
be avoided the possibilit}^ of super-imposing a severe arsphenamine intoxi-
cation upon a patient already suffering from acute nephritis.
The influence of specific treatment upon the Wassermann reaction of
the blood should be watched during the course of treatment — a test being
made a month after completion of the first course of mercury and subse-
quent tests being made at the interim intervals during the various courses
of the treatment. The blood test may prove a valuable guide to further
treatment, but it should be kept in mind that in a certain number of cases
serological cure is impossible.
In the gonorrhoea cases, examination of smears aids the clinician to follow
the progress of treatmenj: — negative urethral and prostatic smears being
some of the usual criteria for determining the patient's fitness for release.
In the follow-up management, syphilitic patients who have been treated
in the clinics are told to report back at stated periods for physical exam-
ination and a blood test. At first these examinations are made at frequent
intervals, keeping in mind that a single negative reaction means little but
that the blood should remain negative over a period of months. Later the
intervals may well be lengthened and the patient be regarded as free from
the necessity of further observation or treatment when examination and
Wassermann tests have been negative at intervals of two months from a
period of at least a j'ear. Most clinicians would state that a routine lumbar
puncture for the purpose of examining the spinal fluid for evidences ot cen
tral nervous svstem involvement should be done at a suitable time during
250 NORTH CAROLINA MEDICAL SOCIETY
the treatment and before dismissing the patient. This should be the pro-
cedure where the clinic has hospital facilities. The follow-up care of the
gonorrhoea patients also necessitates their reporting for examination, includ-
ing examinations of smears, at intervals outlined by the physician.
The chief value of having laboratory facilities close at hand, as a part
of the clinic, will lie in the ease and readiness with which the desired ex-
amination can be made, leaving the clinical members of the stalif free to
handle their own numerous duties. The laboratory's aid will make for
more exact and complete diagnosis and will place the treatment upon a
more direct course and the subsequent management upon a more logical
basis.
GONORRHOEAL COMPLICATIONS IN THEIR RELATION
TO INFECTIVITY.
By Dr. A. F. Toole, Asheville.
From the preceding papers of this symposium you have doubtless caught
the angle of today's viewpoint on venereal diseases. It is an angle which
gives us a focus not on the individual patient's symptoms, not on the pathol-
ogy and treatment of the case itself, but a focus on the infected patient as
a carrier of disease and as a menace to the uninfected- Gonococci and
spirochaetes hit the individual, but tend to rebound toward the general
public, thereby creating a health problem ; so, of course, with every infec-
tious disease.
Prior to the time when preventive medicine began to take on some of
its present and promising activity, gonorrhcea and some of its complications
were handled in almost numberless papers, from predisposing causes to
prognosis, with a maximum of attention to pathology and treatment, but
a minimum — too often — toward infectivity. My brief remarks on gonor-
rhoeal complications will therefore be confined to such as conform to the
above angle.
As a matter of fact, the complications of the disease outrank in impor-
tance the disease itself, in that the problem of prevention revolves around
them instead of around the simple infection. Indeed, that all-too-rare oc-
currence — an acute uncomplicated gonorrhoea — is relatively a small prob-
lem, since we have here to deal merely with a surface infetcion of the
mucosa of the anterior urethra, easily controlled, easily cured, and of brief
duration. Its victim is relatively innocuous as a spreader of disease, since
he is inhibited partly through his own discomfort, partly through a variable
and limited restraint imposed by his conscience and sense of decency, from
inflicting his visible and recognized infection upon others. Exceptions to
such exercise of moral inhibition are of course numerous; perhaps, if or
when alcohol is introduced as a factor, almost as numerous as the c?ses
cited for the rule ; but beyond doubt the real male infector is he who carries
a chronic gonorrhoea; and a chronic gonorrhoeic is merely one whose acute
gonorrhoea has been attended by one or more complications- Or we may
state our equation as follows: — Complications produce chronicity, and
chronicity multiplies new infections.
The crux of our problem, therefore, is the prevention or detection of
complications. These may develop insidiously; once developed, they are
PUBLIC HEALTH AND EDUCATION 251
often unrecognized by the patient and far too often undiscovered by his
medical adviser. Yet recognition, or discovery, or diagnosis, of them is
always possible; which is fortunate, since such recognition is essential to
that particular treatment which alone can render the quondam carrier non-
infectious.
In what ways are we to handle this problem of complications? I shall
suggest a few, with brief remarks on each as I proceed :
First. — Continue our attack on the patent or proprietary nostrums, and
on the counter-prescribing druggist. There was a time when some weakly
plausible arguments were advanced in extenuation ; but if ever there did
exist any justification for this abuse, these arguments are scarcely valid
now. I do not believe there is any other agency so potent in the production
of gonnorrhoeal complications and in their perpetuation. Nor is there any-
thing which so spreads and fosters the untruth as to one mode of treatment
being applicable to all stages and kinds of gonorrhoeal infection.
Second. — ^Anything which will discourage or minimize the above prac-
tice will encourage the habit of coming early to the doctor or clinic for
treatment, before complications have set in. As it is, the average gonor-
rhoeic is inclined to hold the doctor in reserve as a last resort ; (a compliment
— if such — too often undeserved-)
Third. — Watch closely and examine systematically for complications
during the acute stage. Subjective symptoms may be slight or absent, and
the onset of complications — even of prostatitis — may be (as said above)
insidious. Gently examine the prostate at intervals throughout treatment ;
employ the sound or the dilator at least once on the conclusion of all acute
or so-called sub-acute symptoms, and where possible inspect the supposedly
healed urethra through the urethroscope.
Fourth. — In every chronic case diagnose the cause of the chronicity;
that is, localize the focus or foci of infection. This should always be the
first step ; in fact, it is the only logical step. Merely to change the patient's
injection is either laziness, or, if possible, worse. You may be sure that
his morning drop is not the outward expression of a single gonococcal
growth on the surface of his mucosa. The main colony of germs has gone
into some retreat ; and one might as well use a gargle for pulmonary tuber-
culosis, as to temporize by shooting in their general direction. The job is
to find them, and it is not so hard a job when undertaken systematically.
Such search would most frequently reveal chronic prostatis as the under-
lying obstacle to recovery ; next in frequency would one find infected folli-
cles along the anterior urethra, and next a localized thickening of some
portion of the urethral wall, — in effect a stricture, even though of minor
degree. I believe one or more of the above three conditions would account
for fully 90 per cent of our cases of gonorrhoeal chronicity.
Space forbids any discussion here of diagnostic procedure ; that I can
leave to the text-books; the point of emphasis just now is the matter of
careful search for the offending focus.
Fifth. — The fifth and the naturally succeeding sub-topic is the applica-
tion of such particular treatment as will rid the focus when found of gono-
cocci. Emphasis on this consists of course in repetition of the truth that
252 NORTH CAROLINA MEDICAL SOCIETY
one must go after each individual condition with special aim and method.
The way to cure a prostatis is not the way to sterilize the anterior urethra.
True, this is indeed obvious; but it is too often obvious theory instead of
practice.
It does, I will admit, call for some degree of equipment and skill hereto-
fore delegated to the all-time urologist; but with equipment and skill
sufficient to handle the average case can be fairly easily acquired. One must
learn the feel of a normal and an abnormal prostate, must learn the ap-
pearance of diseased prostatic secretion as seen under the microsope, and
become familiar with the appearance of the healthy and the diseased urethra;
the possession of sounds is far more common than is skill and gentleness in
their use; and a Kohlman dilator, if em.ployed with a due regard for its
power to do damage when handled recklessly, is a valuable adjunct to the
armamentarium.
And just here let me assure you that careful diagnosis and proper treat-
ment pay, in every sense of the word. For even those patients seemingly
most ignorant are rapidly learning to distinguish between the old shot-gun,
hit-or-miss modes of treatment, and treatment which they can see is aimed
at their own individual troubles. This is daily evident in the clinics; in
fact, I must say that taking it all in all', the laity has responded more keenly
to the nation-wide propaganda against these diseases than has the profession.
You may be certain that for every chronic gonorrhoeic coming to your office
there is a little crowd of boon companions on the invisible sidelines watch-
ing the game, and keeping their eyes on that morning drop ; if you win,
the procession will file in ; if you lose, the next gonorrhoeic will be a
straggler.
But careful diagnosis and proper treatment will pay of course in the
best sense through the satisfaction gained in helping to refute the old fallacy
which claims that gonorrhoea is incurable, and through lessening the spread
of the disease by changing a patient from a carrier to a sexually sound
citizen.
Summary: By way of repetition, let us say:
(1) That gonorrhoea is spread by the victim of the chronic form thereof;
(2) That this chronic stage depends upon the development of some com-
plication during the acute stage ;
(3) That to lessen the occurrence of complications, we should
(a) preach early medical attention,
(b) fight nostrums and prescribing drug-stores,
(c) closely watch acute cases for complications;
(4) That to properly attack complications when chronic, we should
(a) locate the infected areas of the urinary tract, and
(b) direct specific treatment against these foci.
THE DIAGNOSIS AND TREATMENT OF SYPHILIS.
By C. O. Abernethy, B. S., M. D., Raleigh, N. C.
I have been asked to say a few words upon the diagnosis and treatment
of syphilis. My excuse for doing so is the following case reports:
public health axd education 253
Case (1)
Mr. J. H., (white) 40 years old, married, came in my office February
15, 1920. Gave history of having had little blisters around margin of
foreskin eight weeks prior to above date. A doctor gave him some bichloride
of mercury^ for a wash and told him "it would not amount to anything."
Examination showed a condition of phimosis, with inflammation and ulcera-
tion of foreskin and glans, due to using too strong solution. Hot applica-
tions reduced the swelling until I could get a dark-field, which was nega-
tive on two successive occasions. Wassermann four plus.
Case (2)
Mr, R. M., (white) 22 years old, single, was seen by us February 14,
1920. He gave history of having been cut by barbed wire fence four months
ago, which caused a sore on penis. Doctor gave him some dusting powder
and pills, and sore disappeared. Examination showed hard knot on fore-
skin just at coronal junction. No abrasion. Wassermann negative. Saw
him again February 20. Knot had increased in size, and finding slight
abrasion demonstrated spirochetes with dark field.
Case (3)
Mrs. W. W., (white) 30 years old, married ten months. No history
of venereal infection. She had a generalized maculo-papular eruption over
body, which had been present for over two months and had been variously
treated. Examination showed general glandular enlargement and slight
abrasion in lips of vagina. Spirochetes were demonstrated from abrasion.
No Wassermann taken.
Case (4)
Mr. W. D., (white) 26 and married, with one child four years old.
He had "flu" in January, 1920, followed by an eruption which was treated
for psoriasis. We saw him April 7, 1920, with generalized eruption which
resembled psoriasis. He had mucous patches in mouth, from which the
spirochetes were demonstrated. Wassermann 4 plus.
Case (5)
Mr. B. S., (white) 22, single. Sore on shaft of penis two months ago.
Had worn a "rubber" during exposure. Now has generalized eruption,
but no abrasion except in folds of mucous membrane of anus, from which
the spirochetes were demonstrated. Wassermann 4 plus.
Case (6)
Showing the possibility of an early diagnosis. Mr. H. B., 21, single.
Saw him April 12, 1920. Two small sores resembling herpes appeared on
penis April 9th. Spirochetes demonstrated from these. Wassermann nega'
tive.
Case (7)
Illustrates that sometimes a positive diagnosis cannot be made.
Mr. W. D., (white) 22 single, had a small sore on penis four months
ago, and was given one antiseptic wash and ulcer cauterized with nitric
acid. Saw him February 23. 1920, with ulcer about the size of half dollar
on under surface of penis at junction of glans and prepuce- Spirochetes
negative and Wassermann negative on several different occasions. We had
254 NORTH CAROLINA MEDICAL SOCIETY
him to soak the penis in normal salt solution, and ulcer is slowly healing-
These cases were selected from my office practice, and not from the
clinic, to show the awful tragedies that are being enacted every day in our
midst among some of our very best people, and to show the importance of
a thorough examination upon every patient, whether suspected or not. Case
( 1 ) was a "well-to-do!" professional man and could not possibly have had
syphilis. Case (2) had an injury to account for his having had a "sore."
Case (3) was a married woman of the very best family, and therefore could
not possibly have had a Venereal disease. Case (4) of course had an erup-
tion following "flu," which could be easily explained. Case (5) wore a
"rubber" and could not possibly have become infected. While case (6)
came for an early examination and "took his medicine." And case (7)
shows the futility of nitric acid cauterization and strong antiseptics.
THE DIAGNOSIS OF SYPHILIS.
The most important point in the diagnosis of syphilis, like everything
else in medicine, is the examination of the patient. Let us not forget that
most of the mistakes in diagnosis are due to lack of examination and not
to ignorance. And remember that the station in life of the patient makes
no difference in the examination. The spirochete thrives in the palaces
of the rich as well as in the hovels of the poor.
The only absolute diagnosis of syphilis is the demonstration of the spiro-
chete pallida. This is usually a comparatively easy matter, provided the
examination is thorough enough. Don't forget that you can often demon-
strate the presence of the spirochete more easily in other abrasions of the
skin and mucous membrane than in the chancre itself. Especially is this
so in abrasions in the anus — mouth and throat. Get the habit of believing
that every "sore" on a penis is spyhilis until you have proven it otherwise.
And while you are proving it be sure not to use any anti-syphilitic treat-
ment.
The Wassermann test is a very valuable adjunct in the diagnosis of
syphilis and should be used in all cases. But remember that the test is late
in appearing, usually being about one month, and that only 85 °(, of them
are correct.
The physical findings are exceedingly important. Let us all remember
that we are still practitioners of medicine and that our judgment in all
cases is important. Don't try to diagnose a chancre from a chancroid by
the appearance, because the man does not live who can do this. Of course,
there are certain differences between the two which makes one suspect very
strongly one way or the other, but there are so many mixed infections that
one can never be certain. But when a patient gives a history of having a
sore, with general glandular enlargement, followed by an eruption at the
regular time, be very slow to give up your diagnosis because the laboratory
findings are negative.
THE TREATMENT OF SYPHILIS.
The only treatment of syphilis is the combined treatment ; that is, using
all drugs at your command that are indicated. Let us get away from the
terms salvarsan treatment and mercurial treatment. One drug is just as
PUBLIC HEALTH AND EDUCATION 255
important as the other, and in the tertiary stage potassium iodide is as im-
portant as both.
I do not care what form of arsenic you use nor what form of mercury,
but I do believe that saturation with both as early as possible is very im-
portant.
If you study the literature you will find almost as many different meth-
ods of using salvarsan and mercury as you have specialists. The method
which we recommend is arsphenamine (which means any of the salvarsan
or neo-salvarsan groups) once weekly and mercury during the same period.
In my office and clinic I use arsenobenzol on Saturday and salicylate of
mercury on Wednesday for six weeks, then only the mercury once a week
for six more weeks. Then I rest from all medication for six weeks. Have
a Wassermann made and regardless of what it shows repeat the above
twelve weeks' treatment. Then, to be certain that I am over-treating
instead of under-treating, I recommend after a rest of two or three months
another twelve weeks course. After this I recommend a Wassermann
every three months for a year, and if they all are negative I discharge the
patient as probably cured.
I think that it is generally conceded that the rest periods between the
courses of treatment are very important due to the fact that the spirochetes
either encapsulate themselves or acquire an immunity against a drug after
given over a long period of time.
CENTRAL NERVOUS SYSTEM SYPHILIS; ITS INCIDENCE
AND TREATMENT.
By Joseph A. Elliott^ M. D., Charlotte, N, C.
Invasion of the central nervous system by syphilis has been recognized
as a clinical entity for many years; however, there has been a great deal
of discussion during the past half century as to the part played by syphilis
in the more remote conditions, viz. : general paresis and tabes dorsalis. To
Esmarch and Jessen belong the honor of first having discussed the relation-
ship between general paresis and syphilis. These observers reported in
1857 three cases of paresis and syphilis in which they attributed the paresis
as due to syphilis. In 1875, Fournier advanced the theory that tabes
dorsalis was due to syphilis. Since that time these theories, so long as they
remained theories, were discussed very exhaustively both pro and con.
With the advent of the Wassermann reaction, and its application to
the spinal fluid, syphilis as the etiological agent was practically established.
Many who admitted that these nervous disorders were syphilitic in origin
were of the opinion that the pathology was due to toxins from remote
foci and not to the invasion of the brain and cord tissues by the organism
of syphilis. They therefore classified these conditions as parasyphilis. Not
until 1912 did the light begin to dawn on this important question, when
Noguchi demonstrated spirochastse pallidre in pathological sections taken
from the brains of paretics. His excellent research stimulated others in
their efforts to confirm his work, Avhich has been done in many instances.
Wile went a step further, obtaining small bits of tissue from living paretics,
and demonstrated spirochaetes both by dark field examinations and animal
256 NORTH CAROLINA MEDICAL SQCIETY
inoculations. He then obtained spinal fluid from paretics, tabetics, and
acute syphilitic meningitis caseis. While he was not able to demonstrate
the organism in the dark field examinations, he obtained positive animal
inoculations in a number of instances from all classes of patients. Thus,
it has been definitely proven that tabes dorsalis and paresis as well as syphil-
itic meningitis are due to active spirochastes localized in the central nervous
system and not, as was once thought, to circulating toxins from a distant
focal infection.
INCIDENCE OF CENTRAL NERVOUS SYSTEM SYPHILIS.
It is now generally conceded that tabes dorsalis and general paresis are
not due to a sudden invasion of the central nervous system producing
symptoms within a short time, but that the processes are slowly progressive
ones and that infection takes place at the time of the general dissemination
of the organisms from the primary lesion. It is no more likely for these
marked changes to take place in a short time than it is for an aneurism to
occur shortly after infection. The pathology of these lesions is one of
slow progressive changes which are manifested first by lymphocytic and
plasama cell infiltration, followed by a replacement fibrosis, which in turn
causes the clinical symptoms.
During the early dissemination of the spirochaetes there may be symptoms
referable to the central nervous system which are due to acute inflam-
matory reactions and which in some instances are undoubtedly the precursors
of the later manifestations of lues. A few years ago the number of cases
of lues showing central nervous involvement was thought to be very small,
due to the fact that patients were not carefully examined for such lesions,
and only those with very obvious clinical manifestations, such as nerve
palsies, hemiplegias, etc., were diagnosed. Today, however, the entire
nervous system is very carefully examined in all cases of syphilis, besides
lumbar punctures are done as routine by many syphilologists- These re-
sults of these more careful examinations have revealed amazing facts.
Fordyce states that from 25% to 35% per cent of patients in the first year
of infection show pathological changes in the spinal fluid, wihile Pollitzer
believes more than half the cases during this period show changes. In 1915
Wile and Stokes made very careful studies on a series of early syphilitics,
in which they had the fundus ocuH, the eighth nerve, and a very careful
neurological examination made by experts in each line of work. They
found that from 60% to 70% of their cases showed some evidence of cen-
tral nervous system involvement. A small percentage of cases showing
no clinical evidence whatever show positive spinal fluid findings, which is
a strong argument for the adoption of the lumbar puncture as a routine
procedure.
TREATMENT.
While there are a few prominent syphilographers who still hold to the
view that central nervous system syphilis can be treated successfullv by
intravenous and intramuscular medication, by far the largest majority have
demonstrated to their satisfaction that intraspinous therapy is an essential
part of practically ever>^ syphilitic's treatment showing such involvement.
This has been demonstrated over and over again by first having failed with
PUBLIC HEALTH AND EDUCATION 257
the former and obtaining results with the latter. I shall not go further
into the merits by which intraspinal treatment has won its place in our
therapeutic armamentarium, but will take up the methods which are com-
monlj' in vogue today. There are three principal ones: 1. Swift-Ellis;
2. Ogilvie's; 3. Wile's. The procedure of Swift-Ellis is well known, and
is, briefly, as follows: One hour after the intravenous administration of
arsphenamine or neo-arsphenamine 40 c. c. of blood is drawn directly into
a sterile centrifuge tube and centrifuged after the clot has formed. The
clear serum is pipetted off and placed in the ice box over night. It is then
heated in a water bath at 56°C for thirty minutes; 12 c. c. of the serum is
diluted with 18 c. c of normal salt solution and introduced into the lumbar
portion of the spinal canal. The amount of serum may be increased at sub-
sequent injections. The criticism that has been made of this method is-
based on the small amount of arsphenamine contained in the serum. To
obviate this defect Ogilvie has modified the method by adding to the serum
a specific amount of arsphenamine. A refinement of the Ogilvie modifica-
tion has recently been published by Kolmer. He gives the patient 0.6
gms. of arsphenamine intravenously and immediately withdraws 25 c. c.
of blood from the opposite arm and expels it into a 50 c. c. sterile centri-
fuge tube to which has been added 4 c. c. of a 10% solution of sodium
citrate. This is agitated to mix the two fluids and centrifuged. To
10-12 c. c. of the clear serum is added from 1-3 to 1 mg. arsphenamine.
The arsphenaminzed serum is then placed in a water bath at 56° C- for
thirty minutes, following which it is ready for injection into the spinal canal.
Wile's method consists in preparing the arsphenamine so that 0.1 gm. is
dissolved in 30 c. c. of freshly distilled water. A lumbar puncture is per-
formed in the usual manner, a 20 c. c. luer syringe is attached to the lumbar
puncture needle by means of a rubber tube containing a glass window and
a metal adapter. The syringe is then low^ered below the level of the lum-
bar puncture needle until 10-15 c. c. of the spinal fluid is collected. To
this is added, two to three minims of the arsphenamine preparation and
the mixture is stirred thoroughly with a glass rod. The syringe is then
raised above the level of the needle and the arsphenaminized fluid is allowed
to flow back by gravity. If the pressure is very high the piston of the syringe
may be inserted and the fluid very gently forced into the canal.
COMPARISON OF METHODS.
The small amount of arsphenamine contained in the serum given by the
Swift-Ellis method is not sufficient to produce an efficient therapeutic
result. On that account Ogilvie devised his modification of this method,
which has proven much more efficient and in many instances has given
excellent results. Both methods, however, have the decided disadvantages
of introducing foreign substances other than arsphenamine into the spinal
canal, which to my mind is an important factor unless it can be proven that
the serum per se has a definite therapeutic effect. Wile's method has the
following points in its favor: First, the arsphenamine is diluted with spinal
fluid, the most logical media to use. Second, the technique is simple.
Third, intravenous and intraspinous treatments may be given within a
few minutes of each other, thereby avoiding an hour's suspense on the
patient's part and completing both treatments before there is time for a
258 NORTH CAROLINA MEDICAL SOCIETY
possible reaction from the intravenous. Fourth, exact knowledge of dosage
of arsphenamine. From the standpoint of technique, etc., this treatment
seems to have decided advantages over the preceeding ones. If its thera-
peutic value compares favorably with the other methods, and it has in oui
experience, its simplicity makes it the method of choice.
While on Dr. Wile's service at the University of Michigan hospital I
had the opportunity of treating, by his method, most of the central nervous
sj^stem syphilis cases for a period of over two years, during which time several
hundred cases were treated. The results were gratifying in over 90% of the
meningitis cases and in a very large percentage of tabetics. Our results in
paresis have been uniformly unsatisfactory. The acute cases, as would be
expected, respond more rapidly than any other class of patients. The cell
count usually comes down very rapidly with a corresponding clearing up of
symptoms. Virtually all cases of early tabes show improvement under this
form of therapy, whereas those with advanced nerve degeneration do not re-
spond readily. This may be explained on the grounds that in early tabes many
of the symptoms are the results of the inflammation present rather than
degenerative changes, and under intraspinous treatment many of the organ-
isms are killed off with a resulting disappearance of the inflammation and
clearing up of symptoms. Once there is degeneration, no amount of treat-
ment will repair the destruction that has taken place in the nerve structures;
however, the process may be halted by treatment, and in many instances one
is impressed with the marked improvement in symptoms. I recall a case that
I treated 3 years ago that was suffering most severely with lightning pains
and whose gait was markedly ataxic- After receiving a course of four intra-
spinous treatments, the pains entirely disappeared and his gait showedsome
improvement. One year later I again saw the same patient, and while he
was still very ataxic he had been entirely free from pains during the interval.
Just recently I had a patient with gastric crises who had received four intra-
venous arsphenamine during the two months preceding the onset of the crises-
She was given an intraspinous treatment and within one hour the vomiting
and pains stopped, although they had persisted for four days in spite of all
other measures.
I shall now present a few lantern slides furnished me through the courtesy
of Prof. Udo J. Wile of Michigan. These slides were made during the
early days of his method of treatment, and I can vouch for the fact that
even better results are being obtained at the present tim.e with the same
technique as employed then, but with a larger number of treatments.
DISCUSSION.
Prof. Udo.J. Wile, of the University of Michigan.
Mr. President and Members of the North Carolina Medical Society:
I wish to express my appreciation for the privilege of listening to these
papers. The hour is so late that I hesitate to take up the very excellent paper
of Dr. Knowlton, which was presented in a very clear cut manner. Those
interested might be helped by studying the law we have in Michigan today.
Michigan was a pioneer state in attempting to frame and enforce a law which
in substance was a good law, and which should have the backing of the medi-
cal profession, but it has not It fails because of a few unfortunate features
PUBLIC HEALTH AND EDUCATION 259
which I think will be eliminated in the next session of the legislature. I
am not qualified to discuss the papers on Gonorrhoea, but I would like to
say a few words to you about the treatment of Syphilis of the nervous sys-
tem. There is no treatment for syphilis which is not intensive. I am
going to make the statement that the unfortunate effects that we see are
a direct indictment against medical practice and medical treatment. There
is no excuse for these venereal diseases or the conditions which result from
• syphilis, except that they are not treated correctly. The proper time to
treat S3^philis is the first week and first month of infection. That is the
time the patient seeks your advice when the patient is from the standpoint
of infection most dangerous. That is the time you have the best chance
to treat him. It is unquestionably a fact that a few weeks of treatment
in the first months of infection is the important thing. At the outset you
deal with a local disease, which very soon becomes a general disease, and it
is believed at this time that you have a chance of eradicating the disease.
After the patient's treatment has been neglected or no treatment whatever
given he is syphilizd, and then his chances for recovery are very slim. It
is only as Dr. Elliott has pointed out, in the late years that we realize
that the disease is braced with nervous infection. I think there is no simpler
thing in the hands of the general practitioner than the examination of
all patients for Syphilis. How else could it be? You have during the first
three or four weeks an infection in the blood stream. The same blood
that goes to the liver goes to the nervous system. It is at that time the
patient is potentially a nervous- wreck. I have been so impressed with this,
that a number of years ago I formulated a little rule which I have written
about and told my students about, that the fate of every syphilitic is de-
termined in the first stage of the infection."
If you are attempting to inject into the spinal canal any foreign sub-
stance, take the substance that is the least irritating and the smallest
quantity. I have felt that the direct application of the minutest dose of
Salvarsan is a method of choice, in cases of paresis or those in which you
have a softening of the brain. I mean he is not the ideal case for intensive
treatment, and you have only the right to expect that by certain treatment
you may get rid of the worst- I have been using this method for six years,
and I can truthfully say that I have never seen an early case of syphilis
develop into syphilis of the nervous system. I have seen a number come
back, but they have been made entirely well. For a case of paresis you
need not wait 10 or 15 years. I have seen it develop 11 months after the
infection. I am sure that we see more syphilis today, first because there
is more syphilis, and, second, there are more diagnoses. In years gone by
we waited for the patient to become blind before we made the diagnosis.
Today we diagnose the case immediately in order to enable us to cure it.
I appreciate the opportunity of discussing these splendid papers and to
impress upon you that Syphilis is a disease which has so many aspects that
it requires intelligence and not routine treatment. Each case is a case of
itself. We must regard the patient, rather than the disease, as n problem.
Dr. Anderson :
I want to express my thanks and I believe the thanks of this entire body
for the exposition of truth we have just listened to- I happen to be in charge
of the State Hospital and I know what these terrible results mean, caused
260 NORTH CAROLINA MEDICAL SOCIETY
by the lack of proper treatment. I wish everyone connected with this work
could know something of the value of this address we have listened to.
I thank Dr. Wile personally, and know all of us feel under obligation to
him for coming here.
Dr. Abernathy:
I also want to thank Dr. Wile for coming here and giving us some real
information about Syphilis. I want to ask him: "Don't you use mercury
at all?"
Dr. Wile:
I think if I had to choose a remedy and use it unintelligently, I would
use mercury itself. Salvarsan cannot be unintelligently used, but there is
no drug that is as unintelligently used as mercury. A number of years
ago I had occasion to analyze some hundred cases of Syphilis, in which
all of the treatment was perfectly plain. We discarded all of those who
had not been treated at all, and took one hundred severe cases in which
treatment had been given. In that number 90% had been given proto
iodide pills. It is the most convenient way for administering mercury
so far as the patient is concerned. In order to saturate the patient you
have to give him such severe doses that the proper treatment is never
reached. It must be an accepted fact that the interrupted form of treat-
ment in the form of injection stands first. I do not mean to say that there
are cases in which we should not use the injection treatment, because young
infants and elderly people present a different aspect. Salvarsan acts very
differently from mercury. There is a time when we do not know what
Salvarsan is doing. I cannot tell anyone how much of that to give a patient
and how much not to. I think a patient should receive it and mercury also.
Dr. C. B. McNairy:
In regard to the children of these people suffering from Nervous Syphilis,
as to the longevity of children and their mental condition?
Dr. Wiles:
If you refer particularly to the children of the patients, I am not pre-
pared to answer, so few have had children, time has been so short. I have
seen numbers of cases where patients have married and had children and
they were alright; but as to children, we have a very interesting problem.
It brings up the whole question of transmission of Syphilis from father
and mother to the child. But it must be admitted, beyond any question,
that they do have perfectly healthy children. I have in mind a dozen,
off hand, and then members of the community whose parents have been
syphilized. Only very recently one of my pupils brought me his fathet
in an advanced stage. I have had a number of cases. I know of a man
who is an excellent man, whose father I treated and whose mother died
of syphilis of the bowels. On the other hand, we find cases where children
are not strong and healthy. But I am prepared to state if a person marries
a syphilitic, then the chances of the children are far less than the one who
marries a woman without syphilis.
Dr. McNairy:
My record shows that most of the children that show affection are th*'
first child.
PUBLIC HEALTH AND EDUCATION 261
^: i
Dr. Wile:
I am perfectly convinced that Syphilis is contagious, but that most feeble-
minded children are not syphilitic; that Syphilis does not play a very big
role in the incidence of feeble-mindedness.
Not very long ago in the State Hospital in Michigan a very careful
study was made, and I think only 3 or 4 per cent was found to be syphilitic.
Their parents had other diseases besides Syphilis, without doubt- Occa-
sionally we found a very direct nervous syphilis in a mother and child. I
know of three young children whose parents had nervous syphilis and all
three of the children developed the disease, but that is a very striking case.
Dr. Crowell, Charlotte:
The field has certainly been well covered this evening. I simply want
to call the attention of the members of the staff to the appalling fact that
it is a very serious disease, and that the early diagnosis, the facts and figures
that have been brought out this afternoon from Dr. Abernathy's paper on
the early diagnosis, the recognition of the disease in its early development
is enough to arouse the profession to its great importance, and to go away
with the determination that they will do more than ever before to prevent
the spread of the disease. I am so glad to see our State authorities taking
hold of this problem with such vigor and may we not hope that the day is
not far distant when these late results will practically be no more, because
if we will carry out the plan of treatment outlined in these papers it seems
to me that we can prevent these late manifestations, treating the patient,
rather than the disease, as Dr. Wile stated.
Dr. McBrayer, R. A.:
With two excellent teachers, Dr. Wile and Dr. Crowell, we have had
a corking good lesson, with help from the others. I thank them on behalf
of the medical profession and the people of North Carolina.
Dr. Abernathy:
We are attacking the problem as a public health problem-
There is no question about the fact that the treatment of Syphilis is alright;
there is no argument about that. But all of us can't use a spinal treatment
for syphilis. We have got to use what we can get our hands on. We are
compelled to use the best way we know how. All the syphilitics in North
Carolina can't come to Charlotte or go to Raleigh and be treated. We
are trying to get the men in the country who know how to do it, or get
so interested in it that they will learn how to do it. I don't know whether
or not I am fully converted that all Syphilitics should be treated by the
spinal canal. I have two cases in my records, paralysis below the waist
which was relieved of paralj^sis and made a good citizen by the intravenous
injection of salvarsan and mercury and large doses of iodine. I don't
know how it got in there, but they were taken out of the bed where they
lay helplessly paralyzed and are now walking around doing their work,
and didn't get any spinal treatment. We are trying to reach the man out
in the woods, the man who has not got the money to go and be treated,
and get some man in that county that can give Salvarsan and Mercury
correctly.
262 NORTH CAROLINA MEDICAL SOCIETY
Men are ready to say we can't go into the diagnosis and management
of these early nervous syphilis conditions. But the time is not far distant
when the men throughout the country will equip themselves to do this
line of work, and we will be cutting out a whole lot of work Dr. Anderson
is doing as the result of Syphilis. He is caring for this a great deal in the
Insane Asylum, and I believe with care of these patients we will prevent
the spread, as well as the nervous cases in the State Hospital.
Dr. Knowlton, closing discussion on his paper:
I would like to say a word or two in regard to the point Dr. Wile men-
tioned concerning reporting. We must not lose sight of the fact that the
primary object of having communicable diseases reported is to permit the
health authority to exercise supervision over the cases that need supervision
in order to protect the public health, as pointed out in one of the papers
I read. "A case of venereal disease, even though they be in the infectious
stages, should be so handled as not to be a menace to the public health."
So it is not necessary to have the names and addresses of all cases reported-
It seems to me that the best practicable solution of that problem — that
has been worked out in several places and applied satisfactorily — is to put
the proposition up to the physician himself as to whether or not he will
report the cases by number. So it seems to me that the common sense,
practical way of requiring reporting gives the physician the option of re-
porting by name and address or by number, which will give the Health
Officer information concerning cases that ought to come under his super-
vision.
Adjourned.
WEDNESDAY, APRIL 21, 2:30 P. M.
The President announced that according to adjournment we would pro-
ceed to ballot for seven members of the Board of Medical Examiners of
the State of North Carolina. Before doing so, Dr. H. A. Royster, Sec-
retary of the retiring Board of Medical Examiners, made the following
report:
REPORT OF BOARD OF EXAMINERS.
By H. A. Royster, Secretary.
To the Medical Society of the State of North Carolina:
The Board of Medical Examiners, elected by you in 1914 and come now
to the close of its six years of service, desires to return to you the trust im-
posed and to render an account of its labors. Each year a report of our
examinations has been published in the Transactions of the Society; but
the members of this Board resolved to present to you a summary of their
complete record, and of their own accord requested the privilege of address-
ing you today.
It will be manifestly unnecessary, and in some respects impossible, to
offer you all the details of the work. What seems essential is to state the
principles which guided our conduct from the beginning, to outline definite
alterations that were made in the laws, to express some of the results
achieved and to propose certain recommendations for your judgment.
PUBLIC HEALTH AND EDUCATION 263
Our Initial controlling desire was to elevate the requirements for admis-
sion to examinations. From the results of our first examination in 1915
it was seen that a large number of applicants were poorly prepared both
academically and professionally and had been unsuccessful before the Board
year after year, running the number of failures up high. Practically all
of these were found to be graduates of schools rated lowest by the Council
on Education of the American Medical Association (Class C). Our plain
duty was to eliminate these applicants. It was further evident that eleva-
tion of the requirements should be gradual, but decisive. Accordingly,
under the statute giving the Board authority to define a "reputable" med-
ical college, the rule was adopted rejecting Class C applicants after 1915
Class B applicants after 1916 and after 1917 accepting only Class A
applicants. This rule has continued in force. Its adoption has reduced
the percentage of failures by one-half, or more, because those who come
from the high grade schools are already qualified by preliminary and pro-
fessional education, and the only question for- a Board of Examiners to
determine is whether by character and attainments these applicants are
competent to practice medicine in North Carolina.
There is still a flaw that prevents the perfect working of our Class A
rule, namely, a proviso in the statute which states that a license in another
State stands in lieu of a diploma and entitles to examination. This amend-
ment was passed before our reciprocity act became a law, and, as it exists
today, nullifies our rule to accept only Class A applicants. It should be
repealed. Two attempts have been made to do so, but each time the re-
sult was a failure, in the one case owing to a misunderstanding fostered
by a medical member of the legislature, and in the other due to physical
loss of the bill in committee. There could be no possible objection to re-
peal of the amendment, since it cannot operate to the disadvantage of any
North Carolina citizen. In the meantime, it must be confessed that this
little proviso has enabled the Board to sidestep the issue of the so-called
"limited license" in particular cases. It may be observed in passing that
doing away with the limited license law may soon come to pass, since it has
fulfiOed its mission and because of a demand even from its legislative
author and some of his constituents to remove the stigma which the act
implies. But this is an affair which coming boards must decide.
One of the innovations adopted by the present Board was the passing
of a law allowing students the privilege of coming up for examination
on the fundamental medical branches — anatomy, physiology and chenn^try,
with their accessory subjects — at the end of their first two years of study.
The Board members were unanimously in favor of this provision and had
discussed the propriety of adopting it on their own motion as a rule* out
it was undoubtedly a stronger feature to enact a law covering the situation,
and the Board acknowledges the help of a member of a former Board who
at the time was a representative in the lower legislative house and who
proposed and introduced the bill. In the opinion of our Board, this change,
on the whole, has worked well. It affords, of course, an imnicnse ad-
vantage to the applicants, while entailing only a slightly increased amount
264 NORTH CAROLINA MEDICAL SOCIETY
of clerical work upon the examiners. With apology for the personal .illu-
sion, it is on record as far back as 1893 that the Secretary of the present
Board was the first to apply for the privilege of passing the first two years'
work separately and that the request was respectfully denied. Thus is fate
reversed.
Very early in its deliberations the Board keenly realized three impor-
tant facts : First, that it would be desirable to divorce its own sessions from
the meetings of the State Medical Society; second, that a permanent place
centrally located would be advantageous both for the examiners and the
applicants; third, that in justice to themselves and to the students, the
Board should take the papers home for inspection and report later and not
grade them during the rush of examinations. Means were devised to bring
about these reforms.
Before the county unit organization plan was agreed to in 1904, it was
vitally necessary for the examining Board to meet just prior to and along
with the Society, for by this arrangement the newly licensed physicians could
immediately be admitted to the State organization. But after 1904 all
new members came in through the county societies, and the need for an
overlapping session no longer existed. Besides, it seemed very desirable to
place the time of examinations later in the summer, long after the closing
of all the medical schools. Further, there was to us a yearning for a de-
tached, quiet session, without let or hindrance, visitors or assistants. Finally,
there appeared to be no valid reason against the change. The law was
amended by act of the legislature without shadow of opposition and with
every commendation for the improvement- Having had one trial under
the old system, we assert unhesitatingly that nothing could induce us to go
back to it.
The question of a permanent place for meeting is somewhat bound up
in the foregoing arrangement. As long as the Board was compelled to meet
with the Society, the transfer of books, records, apparatus and other para-
phernalia entailed expense, trouble and losses. Previous Boards had no
chance to accumulate fixtures, to develop enduring plans for conducting
their examinations or to carry on efficiently the routine work of the Secre-
tary's office. The advantages of a central location for the permanent meet-
ing place are obvious. It means a saving of time, money and labor for ex-
aminers and applicants. Our law now provides that the principal meeting
shall be held each year in the city of Raleigh, but that other meetings may
be called there or elsewhere, in the discretion of the Board. It is but fair
to say that the resolution calling for this change in the law was introduced,
not by a member of the Board living in Raleigh or vicinity, but by a mem-
ber from the western section of the State. The Board is now of one mind
in declaring the step wisely taken and more than justified by the results.
What the incoming Board may decide to do with this matter will depend
upon availability, geography and personality.
Under the old regime, when the Board assembled one week in advance
of the Society session, they were forced to do their work under high pressure,
using every moment night and day in which to get their report ready for
the first day's meeting of the Society. The members of the present Board
frankly felt unwilling to continue this method, if possible to avoid it, after
PUBLIC HEALTH AND EDUCATION 265
their one trial in 1915, when 134 applicants presented themselves for ex-
amination. As soon as the conditions were changed there was no occasion
for an oral report and no hurry for the inspection of examination papers.
The safe and sound policy at once suggested itself, namely, to grade the
papers carefully and leisurely, giving such time as might be necessary for
deliberation and discussion. The custom of this Board, therefore, has been
for the examiners to take their papers home, read Vnd mark them at their
own convenience, forward the grades to the Secretary as soon as completed,
and then about two weeks after the examinations to meet for conference.
Immediately following this, the names of the successful candidates are
published as required by law. The relief and the satisfaction gained by
this improved procedure can be felt only by those who have had experience
of both the old and the new method.
In the foregoing discussion of the three important objectives which the
Board set out to reach and finally attained, it will be observed that the first
move was the most essential. Indeed, upon the separation of the Society
and Board .sessions everything hinged; for the selection of a permanent
meeting place and the orderly examination of papers could not have been
accomplished without a change in the law which formerly required the two
bodies to meet near each other in time and place. So far from pulling them
apart, however, the new plan really brings the Board and the Society closer
together; for it allows the examiners greater liberty to attend the Society
meetings and accentuates their responsibility and their co-operation. It
should constantly be emphasized that the Board is the creature of the So-
ciety, and the present Board has sought to strengthen this relation, believ-
ing that the selection of its members by the Society in open session is the
soundest method whereby expression of its will may be made by the larger
organization and through which the smaller body may accept its obliga-
tions.
An inspection of the former laws relating to the prosecution of illegal
practitioners caused us to realize very promptly that they were inadequate.
These prosecutions had been left to the local societies or to individuals, and
there was no definite machinery for the conduct of such cases. There was
no provision for the Board itself to handle them. We were convinced that
a Board that had power to give license should have the power to prosecute
those who violate the law under which it was created. We felt that these
prosecutions should be taken out of local hands and placed in those of a cen-
tral authority, and that at the same time rules should be made for beginning
the actions and carrying them on to successful conclusions. The outcome
of our efforts was the present law, passed without opposition, founded on
a like measure which had proved adequate in other States. It provides,
in effect, that upon complaint of the Board of Examiners the Attorney-
General of the State shall investigate the case, and, if in his opinion, the
law has been violated, he shall direct the Solicitor to prosecute, and the
original jurisdiction shall lie in the Superior Court. The strong elements
appear in this law, viz. : the psychological power of the State's chief prose-
cutor, his direct control over the district solicitors (as set out in the con-
stitution, but not generally recognized), and the primary handling of the
cause in the Superior Court instead of by a magistrate. Thus each case
is divested of its local color and so-called personal prejudice. It immedi-
266 NORTH CAROLINA MEDICAL SOCIETY
ately becomes a State-wide matter — an offense against a North Carolina
statute, and not merely a community affair. The effect of the operation of
this law has been most satisfactory. By its aid we have been enabled to
convict or drive out of the State a dozen of the most notorious quacks and
in addition to eliminate at least a score of lesser offenders. At times the
routine letter from the Attorney General's office is all that is required to
deter would-be violators of the law. No such results could have been ob-
tained without the employment by the Board of its own attorney, as sug-
gested in the act, and this Board goes on record as having been the first to
make such an arrangement. We give it our unqualified endorsement. The
services of a legal advisor are vital and especially if he is available to rep-
resent the Board and assist the Solicitor in any court in the State. During
our incumbency the license of one physician has been revoked because of
conviction in court of criminal abortion. Only fcne cause is now in our
statute for revoking a medical license — grossly immoral conduct. At best,
this is vague and indefinte. The number of causes should be increased and
proper methods prescribed for procuring the result.
No attempt has been made to cover all the points which might be sub-
jects for discussion. The Board is conscious of its limitations in making
its report at this session of the Society. There is one more examination for
us to hold, and we are not able, therefore, to include all of our work in the
summary given. But at this meeting you will elect our successors, who,
thanks to the separate meeting of Society and Board, will have the advan-
tage of attending examinations before their term of office begins. We
tender them (whoever they may be) a cordial invitation to join us at
Raleigh on June 21, 1920, and engage with us in the conduct of our last
series of examinations. It is to them that this report is largely addressed,
for we know the burdens and the labors which lie ahead of them, and if
it is in our power to lighten the load we are only too glad to do it. The
fact that the incoming Board will have the benefit of consultation and dem-
onstration beforehand (which we did not have), precludes the necessity
of recommending a return to the old plan of electing two examiners every
other year. But for this attendance on the retiring Board's examinations,
we would be sorely tempted to advise the fractional system ; for the assump-
tion of office by seven*perfectly new men, with no hold-over to furnish in-
struction or encouragement, is not an alluring prospect, to say the least.
There has been so much pleasant association, so great reward in duty
honestly performed and so many opportunities for service that we have been
forced to forget the toil and the tribulations. Among the members of this
Board have existed the most affectionate feelings, the closest comity, the
greatest good-will and the sincerest devotion to the same high purposes.
All of these outweigh any sacrifice or labor or time or trouble.
We hope for our successors the same harmonious relations that have
attended our deliberations. Differences there have been, but none created
or held in a spirit of rancor, and always there was a sense of right and justice
prevailing. We had always before us the consciousness that we were in
fact officers of the State, commissioned to protect the people from imposters
and incompetents, not dealers in favors or promoters of the unfit. An ab-
solute standard and rigorous enforcement of rules represented our ideals.
PUBLIC HEALTH AND EDUCATION- 267
We are turning over to the next Board certain financial and physical assets
— things which were not in our hands when we assumed office. That these
will be made proper use of goes without saying. The new Board will
possess benefits never before granted to any other. We wish for them an
abundance of success.
General Session
Wednesday, April 21, 11 :15 A. M.
NOMINATIONS FOR MEMBERS BOARD OF MEDICAL
EXAMINERS.
Meeting called to order by Dr. Reynolds.
"We have met here for the purpose of receiving nominations for seven
members of the Examining Board."
Dr. Faison:
Gentlemen of the North Carolina Medical Convention, I want to intro-
duce this resolution:
"North Carolina State Medical Association, in annual convention assem-
bled, sends its greetings to the distinguished head of the nation — President
Woodrow Wilson, and pfay for him a speedy and complete recovery and
express our continued confidence in the righteousness of his guiding hand."
Motion seconded. Carried.
Dr. Moore, Elm City:
North Carolina has four candidates for its Governor, and one open
aspirant for the National President. May we indulge in the hope that in
the month of June, on the shores of the golden west, he will pluck the fruit
from the tree which bears his name. The North Carolina Medical Society
is not ready for an election which I now conceive to be of the highest im-
portance, both to the profession and the State. Modesty is more a heritage
than a seeming virtue. If we make an error it is our error. If we blunder
in our choice it is our fault, and the responsibility as well as the penalty will
be ours. Suggesting one man as a member of the Board of Examiners to
be elected, whom I would endorse as a capable and worthy as trusty and
still worthier of a further trust, I take great pleasure in presenting to you
the name of Dr. E. T. Dickinson, of Wilson, N. C-
Dr. Brooks, of Blowing Rock, nominated Dr. Carl Reynolds of Ashe-
ville.
Dr. Fletcher, of Asheville, nominated Dr. D. E. Sevier of Buncombe.
Dr. J. P. Monroe, of Charlotte, nominated Dr. L. A. Crowell of Lincoln-
ton, N. C.
Dr. J. W. Long, of Greensboro, N. C, nominated Dr. D. A. Stanton
of High Point, N. C. (Seconded.)
Dr. J. E. S. Davidson, of Charlotte, placed in nomination Dr. L. N.
Glenn of Gastonia, N. C. (Seconded.)
Dr. Cramner, of Winston-Salem, placed in nomination Dr. J. G. Murphy
of Wilmington, N. C.
Dr. MacNider, of Chapel Hill, placed in nomination Dr. C. A. Shore
of Raleigh, N. C.
Dr. J. T. J. Battle, of Greensboro, placed in nomination Dr. W. M.
Jones of Greensboro, N. C. (Seconded.)
Dr. J. F. Highsmith, of Fayetteville, placed in nomination Dr. W. P.
Holt of Duke, N. C (Seconded by Dr. E. B. Glenn of Asheville.)
GENERAL SESSION
269
Dr. J. M. Templeton, of Gary, placed in nomination Dr. J. Rainey
Parker of Graham, N. C.
Dr. C. B. McNairy, of Kinston, placed in nomination Dr. L. A. Crowell
of Kinston, N. C.
Dr. H. D. Stuart, of Monroe, placed in nomination Dr. Sam Stevens
of Monroe, N. C. (Seconded.)
Dr. Cyrus Thompson, of Jacksonville, placed in nomination Dr. K.
P. B. Bonner of Morehead City.
Dr. W. H. Scruggs, of Asheville, placed in nomination Dr. F. W.
Griffith of Asheville. (Seconded.)
Dr. J. R. Alexander, of Charlotte, placed in nomination Dr. B. J.
Witherspoon of Charlotte, N. C.
Dr. M. A. Adams placed in nomination Dr. J. W. McConnell of David-
son, N. C.
Dr. Bullitt, of Chapel Hill, placed in nomination Dr. Fletcher of Ashe-
ville, N. C. (Dr. Fletcher stated he had served six years on that board
and requested that his name be withdrawn, which was granted. )
Dr. J. L. Spruill placed in nomination Dr. H. D. Walker of Elizabeth
City, N. C.
Dr. E. B. Glenn, nominated Dr. Percival Bennett of Bryson City, N. C.
Nomination closed.
General Session adjourned to 2:30 P. M.
The President declared balloting for seven members of the. Board of
Medical Examiners of North Carolina in order and the balloting was
proceeded with. Dr. Cyrus Thompson reported for the tellers that each
of the following gentlemen had received a majority of all the votes cast:
Dr. L. A. Crowell, Charlotte; Dr. K. P. B. Bonner, Morehead City;
Dr. W. M. Jones, Greensboro; Dr. C. A. Shore, Raleigh; Dr. J. G.
Murphy, Wilmington ; Dr. W. P. Holt, Duke ; Dr. L. N. Glenn, Gastonia.
Dr. Thompson stated that this was the first time in the history of the
Medical Society of the State of North Carolina that seven members of the
Board of Medical Examiners of North Carolina had ever been elected on
the first ballot.
Thereupon the President declared the gentlemen named above duly
elected for a term of six years, beginning at the expiration of the term of
the retiring Board, June, 1920.
WEDNESDAY, APRIL 21, 3 P. M.
Dr. Tom A. Williams, Washington, D. C. :
The oldest body in this country devoted to sociological medicine is the
American Academy of Medicine. It is a body the requirements for mem-
bership in which include a medical degree plus an academic degree. It
has been decided that the latter qualification shall no longer be necessary.
I have been asked to make an announcement to the several societies which
I am going to visit that the American Academy of Medicine wishes to
enlarge its membership. What it has done is well known only to the
270 NORTH CAROLINA MEDICAL SOCIETY
public health workers and the sociologists- It was the forerunner of most
of the public health movements which are now interesting us and in which
the laity are beginning to be interested: I have with me a list of the
publications of the body, and it is most impressive. This sheet contains
merely the titles of the publications of that organization. They were all
published in the Journal of Sociological Medicine. Those who are inter-
ested in this association have only to write to the secretary, Dr. Grayson,
of Pittsburgh, or to me, stating their interest and that they wish to join.
For the membership fee one obtains the Journal of Sociological Medicine,
and the privilege of attending the meetings, which occur once a year, and
of taking part in the discussions. A great body of literature is also sent.
I shall be very glad if those who are interested will take from the table
one of the catalogs of publications. If those who are further interested
will then write to the secretary. Dr. Grayson, in Pittsburgh, or to myself,
they will be put in touch with a body which has done and we hope will
continue to do most fundamental work for the benefit of the cornmunity,
as well as in raising the standard among medical men engaged in sociological
work.
ELECTION OF MEMBERS OF NURSES' EXAMINING BOARD.
Wednesday, April 21, 6 P. M.
Dr. Reynolds, President:
The election of a member of the State Board of Examiners for Nurses is
now in order.
Dr. L." B. McBrayer nominated Dr. D. E. Sevier,* of Asheville for this
place. The motion was seconded and unanimously carried.
Board of Examiners for Trained Nurses: —
Miss Lois A. Toomer, President, Wilmington.
Miss Effie E. Cain, Secretary-Treasurer, Salisbury.
Miss Mary Laxton, Biltmore.
Dr. J. M. Parrott, Kinston.
Dr. C. F. Strosnider, Goldsboro.
Wednesday Night, April 21, 8:30 P. M.
Dr. W. P. Whittington, Asheville:
It gives me great pleasure tonight to have the privilege of introducing
to you — without any flowery speech, for I think the flowery part of the
speech-making was done this morning in nominating candidates — Dr. Wil-
liam L. Clark, of Philadelphia, who is lecturer on applied electricity at
Jefferson Medical College and co-worker with John Chalmers DaCosta,
whom we all know and love. Dr. Clark will give a lecture on "New
Conceptions Relative to the Treatment of Malignant Diseases and Some
Other Refractory Pathological Conditions," illustrated by lantern slides.
Dr. William L. Clark, Philadelphia:
I desire to thank the Committee on Scientific Work and the Society for
*Dr. D. E. Sevier resigned on June 4, 1920, and Dr. J. M. Parrott,
of Kinston, was elected to serve until the Medical Society shall have elected
a member to serve a three-year term.
GENERAL SESSION
271
the invitation to speak to you tonight upon some matters of mutual interest,
and I am glad to renew acquaintance with various members of the Society
whom I have met from time to time. I am also glad of the opportunity
to present some of my views upon the cancer problem, especially, and upon
some other pathological conditions as well.
During the last twelve years I have devoted my best thought and study
to the management of cancer cases. I have had the opportunity of seeing
a large number of all types of cases in almost every possible anatomical
location. This subject is a very broad one, and we are very far from the
solution yet- I may say, however, that much progress has been made in
the last few years, and there are some phases of the cancer question which
I believe I may say have been solved. There are some very malignant types
of internal cases about which we do not yet know much, but so far as the
skin cases are concerned I believe they have been solved.
Until we find the exact cause of cancer we have very little upon which
to work. It may be that like a bolt cut of a clear sky the discovery of the
real cause will be announced. It may be then that we shall have a specific
for cancer, as we have a specific for diphtheria and other conditions. But
at present local attack seems to be the best w^e can do, and until we find
the cause of cancer and find a specific we must devote our energies to the
best way of attacking cancer locally.
We have different degrees of malignancy in cancer.
We have the type that progresses slowly and never metastasizes. If we
get it in its entirety, we may expect a cure. It may recur sometimes, but
that is due to bad technique or lack of thoroughness. With the squamous,
slow type, involving mucous membranes, we have a different type of cancer,
one that metastasizes early, and we can never tell where we are. For-
tunately, however, we have ways and means for combating that, which I
will discuss later.
The methods worthy of consideration at the present time are operative
surgery, which we cannot do without in many phases ; radium, dissection,
and the Roentgen rays. Of course, results are obtained oftentimes by
our escharotics, carbon dioxide snow, etc. Sometimes results are ob-
tained, but more often bad results than good ones. My experience
in my own work, and my observation of the work of others who have had
considerable experience with these pastes, etc., have led to the conclusion
that good results are due more to good luck than to 'anything else. How-
ever, some results are obtained by their use, and sometimes it is impossible
to have other facilities, and of course then we are justified in using these
pastes, etc. But if other means are available we should use them.
Of course, all the methods are valuable, and all have their distinct place.
However, the surgeon who depends upon surgery alone, the electrical man
who depends upon electricity alone, the radium man who depends upon
that alone, will fail and will not do justice either to his patients or himself.
A man who makes a pretense of specializing in malignant disease should
be able to treat malignancy from every angle. He should know the indica-
tions for every method of treatment. Therefore, my experience has been
that to obtain the best results by local attack we should be able to use these
tried methods in combination. I have a great many slides showing various
272 NORTH CAROLINA MEDICAL SOCIETY
angles of this work, and what has been done up to this time and what may
be expected in the future. Some phases of it are a treatment hitherto
unpublished, to which I shall allude as I go along. I shall be glad to have
you ask any questions which may occur to you.
Radium is a method which gives good palliative results in uterine cases.
Radium needles have cleared up some uterine cases, though none have
passed the five-year limit. Rectal cases are the worst of all. Uusually the
liver is involved. They are bad cases.
There is a big field in our dissection method in surgical tonsils. Our
ordinary method of destroying tonsils with a snare or taking them out is
perfectly satisfactory- But there are other cases in which we may use the
dissection method as a very worthy substitute for our surgical procedure.
It can be used also for destroying hemorrhoids. There are many other uses
for these methods, but as my time is up I cannot mention them now.
STATE MEDICINE.
W. S. Rankin,
Secretary North Carolina State Board of Health, Raleigh, N. C.
My understanding is that the Secretary of the Society endeavored to
get several men — men of national reputation, and men who have been
giving a great deal of time to this question of State Medicine, what it is
and what it covers — to discuss it before you. They were unable to get Dr.
Lambert and Dr. Warren, of the United States Public Health Service.
So finally Dr. McBrayer had to fall back upon me, and he consigned the
entire subject to me.
Definition : This term has been applied at different times and places
to various activities undertaken by collective and sovereign people for the
treatment and prevention of human diseases. It has been applied to steps
faken by states in determining the qualifications of those who should attend
their sick; it was applied in the 80's and 90's to the official acts of boards
of health ; in England and in Europe the term when used today refers to
social insurance. Obviously, before entering into a discussion of this sub-
ject, which has come to mean different things to different persons, it will
be necessary, in order to forestall useless discussion and to prevent mis-
understandings, that we all have the same conception of the term. For
this purpose I think the following definition will pass muster: State
Medicine is any part which a state or any of its constituent parts may
assume in combating disease.
The Basis of State Medidine: State Medicine was foreordained and its
secure foundations laid on Sinai. The ten great basic principles of civilized
law there established follow a significant order: In the first four God defines
man's relation to Himself; in the fifth, man's relation to his home; and
in the last five, man's relation to his fellow-man. The first of the laws
defining man's relation to his fellow-man is the law protecting human
life, and protecting it from every agency and factor which may contribute
to its destruction. After the words "Thou shalt not kill" there are no
provided howevers, permitting life to be destroyed in some particular
manner or manners. This law applies to the individual man, but it is
GENERAL SESSION 273
not restricted to the individual ; it applies to man collectively, to the group,
to the citizen, to the state. This law forbids the destruction of life by
willful acts of commission and by careless, passive omission ; it forbids the
destruction of life in murder, by violent and sudden means; it forbids the
destruction of life by the almost imperceptible and long-drawn-out imposition
of conditions on men, women and children that slowly sap their energy,
their blood and vitality through a course of years. This law commands that
the individual and citizen not only refrain from acts that kill suddenly and
that kill slowly, but it commands that we shall not neglect or refuse to do
anything that, left undone, would result in the loss of life. As the oppor-
tunity to save life exists until the last breath, the law "Thou shalt not
kill" requires the individual and the state not only to prevent disease, but
also to see that diseases are properly treated and cured, where possible,
covering, therefore, both the field of disease prevention and that of medical
relief.
Sub-divisions of State Medicine: As suggested above, there are two
main sub-divisions in State Medicine: Disease pr.evention and disease cure.
The first, disease prevention, is the more important of the two. The
population, the well, with which it is concerned is thirty-three times the
size of the sick population. The dividends on money and energy invested
in disease prevention and in the promotion of health — in keeping the fit
fit and making them fitter — are much larger than the dividends on invest-
ments in the repair of broken-down vital machinery- The fact that the field
of disease prevention is the larger does not altar the related fact that the
field of medical relief is large enough to justify the best efforts of both
the individual and the citizen. The citizen of the State cannot draw an
arbitrary line between health and sickness and say "to this line the respon-
sibility rests upon me of saving life, but beyond this line, in the field of
cure, of medical relief, neither I nor my State have any responsibility; the
case is wholly with the medical profession." The obligation, with the
individual and citizen, to save life exists until life is gone, to the very last
breath. Moreover, the treatment of the sick, the cure of disease, is a very
necessary means of preventing disease. This Is particularly true in prevent-
ing tuberculosis and venereal diseases With this general statement as to
methods of State Medicine, we shall proceed now to the consideration
of the more important special activities undertaken by the State, first, in
the field of disease prevention, and, second, in the field of medical relief.
DISEASE PREVENTION.
1. Vital Statistics: A division of vital statistics in state government is
the exact parallel or counterpart of an intelligence division in an army.
It is the business of an intelligence division in an army to ascertain the
number of the enemy, the position of his various units — cavalry, artillery,
infantry, aviation, etc., where an attack on him is likely to be most ef-
fective, and if and where the enemy expects to attack. The vital statistics
division of a state government has identically the same essential function.
Its business is to determine the size of the enemy, his potential power to
destroy life and health, his divisions into various diseases, the location within
the state, the counties, towns and townships where these diseases are most
prevalent, and to ascertain where an attack on preventable diseases is^
274 NORTH CAROLINA MEDICAL SOCIETY
likely to get the biggest returns for the expenditure to be made, and where
disease is next likely to attack. Without birth, death and morbidity statis-
tics the ship of state sails an uncharted sea of human life ; it has neither
log nor compass, and cannot know whether it is drifting backward or
moving forward. I may say, on account of the professional character of
this occasion, that the only incontrovertible proof of the large contributions
of medicine to human progress is in the form of statistics, the declining
death rates following and closely related to medical discoveries. Do away
with the statistics, which some of the short-sighted, over-worked members
of the profession hate so much to assist in collecting, and you do away with
the material proof of medical achievement and with much of the glory
of our profession.
2. Health Education : In the recent war the Government found it
necessary to mobilize the resources, military and civilian, of the entire
nation. The co-operation of all the people was absolutely essential in
undertaking to carry to a successful conclusion our preparedness program.
To secure that co-operation it became necessary to inform the people by
every known educational method — press, moving picture, pamphlet, the
living voice — of the reasons for the war, of the purpose of the Government,
and of the part each and every individual could play and should play in the
winning of the war. The war with Germany has been won. In the
winning of that war North Carolina lost approximately 1,000 men killed
in battle, and had 4,000 others wounded. The war against preventable
disease has not been won; it continues, and we have every year 10,000 to
12,000 unnecessary deaths and from 100,000 to 150,000 wounded in this
as yet unsettled contest. Our loss annually in the fight against preventable
diseases is from twelve to fifteen times greater than our loss in the war
against Germany which we helped to win. Educational methods for in-
forming all the people of the reasons for the war against preventable dis-
ease and death and the part that each and all can play and should play is
just as necessary in fighting preventable diseases as it was in fighting pre-
ventable autocracy. Health education is the primary and most fundamental
activity of the state in maintaining and promoting its public health.
3. Quarantine: A quarantine service has a reason and purpose for its
existence, as a fire department. It is to put out a fire, but a fire that burns
and destroys, not wood, but living human flesh. A quarantine service is
dependent upon the intelligent service of the health department, upon the
health department's ability to get prompt and complete reports of the human
fires, the contagions that break out. If the fire is not reported there can
be no response by the department entrusted with its control. None of the
measures of quarantine, the details of which it is unnecessary to go into
here, can .be thrown around an unknown source of infection to prevent it
from involving a community and distant sections of the state.
For the notification of the health department of the existence of con-
tagious disease the public is dependent very largely upon the practicing
physicians. I say very largely because there are many contagious diseases,
and of a deadly nature, notable examples of which are measles and whoop-
ing cough, that in many instances are too mild to call for a physician, and
in such cases the public is dependent upon the intelligence and the willing-
GENERAL SESSION 275
ness of the citizen to undergo the possible inconvenience of quarantine as
a result of reporting contagion in his own family. Proof is at hand to show
that North Carolina physicians deserve to be commended for reports of con-
tagious diseases. Only in typhoid is their record bad. To illustrate : In
1919 there were 427 deaths in North Carolina from typhoid, and in the
same year 2,956 cases were reported. Either the physicians are not report-
ing all of their cases of typhoid or the North Carolina medical profession
is losing about fifteen patients out of every hundred persons that have
typhoid fever, whereas the average profession loses not more than ten per
hundred.
When a case of contagion is reported the responsibility is then upon the
health department, the public, to make use of the report and to see that
the disease is effectively quarantined. Health departments are not justified
in inconveniencing either the profession or the public to report infectious
diseases unless the health department maks full use of the report by im-
mediately enforcing the State laws, rules and regulations applying to con-
tagious diseases.
4. Vaccination : Certain vaccinations, notably the vaccination for the
prevention of smallpox and the vaccination for the prevention of typhoid
fever, have been demonstrated to be almost 100 per cent effective. The
furnishing free of cost of these established vaccines to all citizens and the
devising and encouragment of the adoption of plans for the free vaccina-
tion of the people is another of the obligations of the state in preventing
unnecessary disease and deaths.
5- Protection of Public Water Supplies: As populations become denser,
as cities multiply, more and more does it become necessary and economically
desirable that individuals pool their interests and as citizens establish com-
mon or public water supplies. While it is possible in certain locations
to secure a fairly adequate and suitable ground or well water supply for
an urban settlement, this is the exception. For the majority of towns and
cities the only available adequate and suitable water supply is the surface
water of streams and rivers. Now a stream used as a public water supply
lies beyond the official jurisdiction always of the city that uses it, and nearly
always of the county in which the city is located, so that the only control
for the protection of the purity of the stream is state control. For this
reason most States, including our own State, have assumed and exercise
a variable degree of oversight and regulation of the watersheds of their
streams, creeks and rivers.
6. Sanitary Control of Important Sources of Disea;,'eS During the last
three years important investigations as to the practicability of eradicating
malaria from thickly settled communities, villages and small towns, through
the control of mosquito breeding by filling, drainage and oiling have been
carried out. It has been demonstrated, notably in Arkansas, that with a
per capita annual expenditure of from one dollar to a dollar and a half for
the first year's work and thereafter an expenditure of from twenty-five to
fifty cents per capita, the prevalence of malaria can be reduced from eighty
to ninety-six per cent. The saving to the people of these communities
in druggists' and doctors' bills and in time lost to productive labor amounts
to five to ten dollars per capita; and this financial saving does not take into
276 NORTH CAROLINA MEDICAL SOCIETY
account the human side of the case — the anxiety, suffering and grief on
account of disease. This important piece of work for controlling malaria
in the more thickly settled communities is now being undertaken, to a
limited extent, in many urban settlements scattered throughout the South.
Another example of the sanitary control of important sources of disease
is the act passed by the recent General Assembly of North Carolina, which
prohibits the open, unsanitary privy in urban settlements. This act was
restricted to urban communities for two reasons: (1) The town unsanitary
privy is more dangerous than the rural unsanitary privy. The town privy
has a fly-range — three hundred yards — on from fifteen to twenty homes,
with a total population of from seventy-five to one hundred and twenty-five
persons; whereas, the rural privy, as a rule, has a fly-range on only one
home with a population of from five to seven. The act, therefore, applies
to the more dangerous type of unsanitary privies, to those that are killing
the larger number of people. (2) The open, unsanitary privy in the coun-
try is under the immediate control of the person or persons injured or liable
to be injured by it; whereas, the urban unsanitary privy is not, as a rule,
under the control of those whose health and life it destroys. The State law'
therefore, in restricting itself to urban privies, protects those individuals
who are exposed to the dangerous closet over which they have no control.
7. The Development of County Health Work : When the Federal Gov-
ernment has done all within its power for a State the State may do much
for itself ; when a State has done all within its power for its counties the
counties may do much for themselves, just as a man can do more for himself
than all assisting agencies together can do for him. One of the larger and
more important objectives of State Medicine is to influence the local gov-
ernments of a state, the counties, to assume a larger part in the protection
of the health and lives of their citizens. This means, of course, the estab-
lishment of full time county health machinery- In North Carolina there
are at present twenty-eight counties with such full time machinery, and
there are ten other counties that have already made financial provision for
either a full time health ofiicer or nurse, or both, as soon as these officials
can be found. Before 1920 has gone fifty per cent of the population of
North Carolina will be living under the protection of some sort of full
time local public health machinery. In this field of public health work
North Carolina excels.
Dependent upon the size of. the budget provided by the county, the fol-
lowing units, or independent pieces, of county health work are being under-
taken: (la thorough enforcement of the State quarantine laws, the en-
forcement of which is always in direct proportion to the intelligence and
courage of the county official; (2) an educational program directed to the
general adoption of sanitary privies in rural homes, to the end that fecal-
borne diseases — typhoid fever, dysentery, diarrheal diseases of infants, or
summer complaint, and hookworm diseases — may be limited in their preva-
lence; (3) the setting up of local dispensaries for giving free vaccination
against typhoid fever and smallpox, and the encouragement by educational
means, of the people to take advantage of the dispensaries; (4) providing
the facilities for and encouraging the people, particularly adults, to submit
themselves for periodic medical examinations in order that incipient disease
GENERAL SESSION " 277
may be detected and referred to the medical profession for treatment before
it has become chronic and progresses beyond repair; (5) an educational
program to interest the general public in the prevalence and the infectious
character of tuberculosis, and to encourage persons with suspicions of the
disease to apply at the office of the county health officer for a preliminary
examination, and in case such person is found to be infected, referred to
proper sources for early and effective treatment; (6) the use of nurses to
get in touch with the mothers of the county, individually and collectively,
and especially with the mothers of bottle-fed children and children suffer-
ing from digestive disturbances, for the purpose of advising them as to the
care of their babies, and in assisting in securing the necessary professional
advice and treatment.
MEDICAL RELIEF.
1. Selecting Those Who Shall Attend the Sick: The States say to cer-
tain persons "you may" and to certain other persons "you may not wait
upon and prescribe for our sick." The practice of requiring persons pre-
senting themselves to the public for the treatment of diseases to comply with
certain conditions, and of excluding those who could not comply with the
conditions, was the first step taken by the States in the field of State Medi-
cine — it was the first recognition by the State of its great responsibility
in seeing that its sick were properly treated. To the credit of North Caro-
ilina it may be said that our State was the first, creating an official board
of examiners in 1859, to see that those who attended the sick were qualified
to do so.
In passing upon the fitness of persons to treat the sick the practice of
the majority of States has been to create commissions or boards of exam-
iners composed of members of those groups that were successful in estab-
lishing their claims with the legislature of being able to heal diseases; then
to require all persons desiring a license to practice some form of healing
to apply to that commission or board that represented the particular system
of treatment which the applicant wished to use.
In following this practice, State legislatures have assumed the responsi-
bility of qualifying, legalizing, and establishing professions. This practice
has resulted in multiple boards of examiners. We have a board of examin-
ers for physicians, and another for dentists, and another for nurses, and
another for optometrists, and another for osteopaths, and another for
chiropractors, and another for pharmacists, and another for veterinarians,
and another for embalmers, and another for plumbers, and perhaps others
of the existence of which I am happily ignorant.
States, in qualifying professions, in legalizing and establishing them ac-
cording to the above described methods, commit two serious errors. The
first error which the legislatures make in this practice is in permitting each
group, those who are financially concerned, I will not say interested, to
determine their own numbers and, therefore, the amount of competition
within the group. Such a practice is inherently vicious. Moreover, as long
as legislatures follow such a practice, havin'j established their precedent,
having cut a deep rut in an unsound foundation, they get deeper and deeper
in the mire in finding themselves unable to refuse tn a new group applving
for a privilege that has been granted to all preceding applicants. The
278 NORTH CAROLINA MEDICAL SOCIETY
second error which legislatures make is in assuming that they are the proper
bodies to investigate and determine the alleged claims of groups to legal
professional standing. They are not. States need for this purpose com-
missions with the peculiar training necessary to determine what are the basic
and common requirements which all persons seeking to treat human dis-
eases within the states should be able to meet. To illustrate my meaning:
Such commissions would require a certain minimum of academic education
for all persons applying for license to treat human diseases; they would
require that all persons, in order to treat human diseases, show a knowledge
of the fundamental biological sciences — chemistry, physics, biology, em-
bryology, anatomy (gross and microscopic) and physiology- These com-
missions would have the scientific training and viewpoint, and what is more
important, they would have the time and the facilities needed to make a
thorough investigation of the claims of any particular school teaching any
system of healing or alleged healing. With such commissions all persons
asking the permission of the States to treat their sick would be fed out of
the same spoon.
The personnel of these commissions on licensure would be composed
of such men as the presidents of the universities, the superintendents of
public instruction, the State commissioners of public welfare, perhaps the
attorney generals, and three or four others selected because of their peculiar
fitness to determine what is and what is not a profession, and to apply the
intellectual tests necessary to determine a person's fitness to practice a pro-
fession. Of course, such commissions would find themselves in need of and
would use representatives of the various professions which they had char-
tered to assist them in determining an applicant's understanding of subjects
peculiar to the group. In this way, the commissions on licensure would
have an advisory sub-committee composed of physicians, and another com-
posed of dentists, another of nurses, et cetera, one for each profession which
the commissions had chartered.
North Carolina was first among the States in establishing the practice
of selecting those who should treat her sick; she cannot now be first in
establishing an impartial and central commission for determining the rights
of groups to establish themselves as professions, but the opportunity yet
waits upon our State and this Medical Society to make North Carolina
one of the first to take this advanced and this inevitable step in the course
of progress.
2. Rendering Asjistance In Diagnosis: States, recognizing that accurate
diagnosis is fundamental in effective treatment, have undertaken already
to fi limited extent and will undertake more and more in the future as
scientific discoveries make possible and as funds become available, ro assist
ph\sicians in the diagnosis of disease. Certain laboratory tests are now
available in most States free of cost to the physicians. Among such tests
which physicians may avail themselves of are to be mentioned the blood
examinations for the Widal, or typhoid fever reaction ; for the Wasser-
Inann, or syphilis reaction, for the malaria parasite, and other blood ex-
aminations ; examinations of the secretions and excretions for diagnostic
criteria, such as swabs from the throat for diphtheria bacilli, sputa from
the lungs for tubercule bacilli, pus for gonococci and other organisms;
GENERAL SESSION 279
feces for intestinal parasites; also nervous tissue of supposed rabid ani-
mals for rabies, et cetera.
3. Assisting Physicians In the Treatment of Disease: Most States have
undertaken to furnish phj^sicians with certain costly curative agents which
require a high degree of technical skill in making them reliable. I refer
especially to the antitoxins, to the treatment for rabies, and to those
selective chemical agents, such as arsphenamine and neo-arsphenamine. I
anticipate that in a few years governments will be producing and furnishing
free of cost, not only all of the now known complex specific remedies, but
many others that future discoveries will unearth.
4. Maintenance of Hospitals: There are certain diseases of a chronic
nature which impose economic burdens upon the family and community
so great that only the strength of the State is able to bear them; hence,
the development of State insane hospitals, on which item alone our own
State expends about $750,000 annually— one-fourth of the expenses of the
State Government, if we exclude funds appropriated for the public sec-
ondary schools. The development of tuberculosis sanatoria is another in-
stance where the State has assumed to a limited extent and will assume
to a still greater extent a burden which it alone can carry; however, in the
case of tuberculosis the reason for State assistance is not only medical
relief, the possible saving of the lives of the sick, but also the prevention
of secondary cases, the saving of the well, by the elimination of the carrier.
5. Medical Relief for Educational Purposes: For many years the State
has realized that its permanency rests with its children and that childhood
is its supremest interest; moreover, the State believes that its childhood
(the State ten or twenty years from now), to bear efficiently the responsi-
bilities of a great government, must be made intelligent and not be per-
mitted to remain ignorant. For this reason two dollars out of every three
dollars collected in North Carolina by the State and local governments are
expended on education, or, in other words, the government. State and local,
expends twice as much for education ^s it does for all other things com-
bined.
Within recent years the State has arrived at the conclusion that mental
development is very closely related to physical vigor ; that to expect a mind
built upon weak vitality to withstand the shifting winds of circumstances
and the currents of adversity is to play the part of the fool who built his
house on the sands. This newer idea in education as to its physical basis
has been expressing itself almost incesasntly and extensively throughout the
country in the establishment of free school lunches, in well-equipped gj^m-
nasia, in playgrounds, and in the employment of ph^'sical directors, and
in the detection and treatment of public school children for the common
defects of childhood, for hookworm disease, bad teeth, defective vision,
enlarged adenoids and tonsils, with impaired hearing, conditions which
retard not only the diseased child, but the whole class in which he recites.
The object of the State in improving the physical condition of school chil-
dren with food, with well directed recreation and with the removal of their
more common physical disadvantages is to insure itself against a tremendous
waste of funds spent on public education. Medical relief restricted to
public school children, not extended to the child out of school or in the
private or parochial school, is an educational rather than a health measure.
280 NORTH CAROLINA MEDICAL SOCIETY
In this connection it may be interesting to know that there is now a bill
pending before Congress, with splendid prospects of passing, which provides
in a most extensive way for the teaching of hygiene in the public schools,
for the development of proper physical exercises and for the completest
system of medical inspection and treatment of school children. The bill
provides an appropriation of $10,000,000 for this purpose, and this appro-
priation is apportioned to the States on a population basis, the apportion-
ment to each State becoming available when the State appropriates a like
amount to that apportioned for the purpose of the bill. In this way, while
the bill appropriates $10,000,000 of Federal funds, it provides for the ex-
penditure of $20,000,000. It is interesting to note that the execution of
this act is under the Bureau of Education of the Department of the Interior,
not under the health service of the Federal Government. In other words,
it is being considered by Congress primarily as an educational measure.
Should this act become a law, as it promises. North Carolina would soon
be expending, either under its Board of Health or its Department of Edu-
cation or under the joint supervision of these two agencies, about $200,000
a year in treating the common physical defects of its 800,000 school children.
Last year, out of a total expenditure of something like $8,000,000 for
public education, the State provided $80,000 for the detection and treat-
ment of the common defects of its public school children. The full appro-
priation did not become available until January 1st this year, so that during
the last ten months only $29,000 in the medical inspection of schools has
been expended. With this expenditure 1,174 children have been success-
fully operated upon for enlarged adenoids and tonsils, and 16,104 children
have had their teeth treated, 29,268 permanent fillings having been made.
This work, if done without the State's assistance, would have cost $96.-
568.90 more than it cost; I say done without State assistance, but let me
remind you here that it has been waiting a mighty long time for State
assistance, and the probability is that it would be waiting still had the
State not come to the aid of these children. Like the poor that "you have
always with you," there are thousands and tens of thousands of children
whose growth and whose mental development is held back by physical
defects so frequent in school children as to have earned the reference "com-
mon defects," and the burden is on this profession to reach these children
in every way possible and to treat everyone that they can persuade to
accept treatment, and the burden is upon the State to see that those who
cannot be reached by the individual physician and the profession collectively
are reached with its longer and stronger arm.
6 Compulsory Social I?7sura?ice, sometimes spoken of as sickness insur-
ance or health insurance.
Compulsory social insurance may be defined as a form of insurance made
compulsory by law for wage earners whose economic status is below a cer-
tain level.
The object of social insurance is to distribute the burden of sickness over
the total period of productive labor of the individual worker rather than tr
rest suddenly and with crushing effect upon the individual or family.
As an illustration of how compulsory social insurance operates, we will
consider briefly the English compulsory social insurance act. In England
about 15,000,000, or a third of the population, come under the compulsory
GENERAL SESSION 281
social insurance act. The act applies to all wage earners and their families
where the total annual income of the wage earner does not exceed, I be-
lieve, $840. Wage earners coming within the group pay 8 cents a week,
the employer pays 8 cents a week, and the government 4 cents a week,
thereby setting aside an insurance fund of 20 cents a week for each wage
earner and his family to care for them and to protect them in case of sick-
ness. I am not informed as to whether the war and the increased cost of
living has affected the rates ; but if it has, I presume that the three parties
— wage earner, employer and the government — are still paying in the same
proportion, 40 per cent apiece for wage earner and employer and 20 per cent
for the government. The equity of this distribution of the insurance fund
rests upon the fact that in case of sickness the employer is responsible foj
his emploj'ees and their surroundings, and is partly responsible for the sick-
ness; the wage earner is also partly responsible for his own sickness, and
the government is partly responsible for sanitary and hygienic conditions,
and, therefore, for sickness; a further reason for the distribution of the
insurance fund among the three parties is that all three parties are bene-
fited in the prompt and effective treatment of sickness and, therefore,
should share in the cost of the benefit. In a case of sickness of an insured
wage earner or in case of sickness in his family, the sick person is treated
free of cost, the government paying the bill out of the insurance fund;
moreover, if during the wage earner's disability the family needs supplies,
they are furnished by the government. The act protects very effectively
against pauperism and charity practice. The fees to be charged by the
physicians registered by the government to accept calls from the insured
wage earner are determined by the government. In England the sick
wage earner may choose his own physician from among those registered
with the government ; and, by the way, 22,000 of 25,000 English physicians
accept these calls ; that is to say, they are registered, or, as they say in
England, are on the panels.
In connection with the operation of this law or with any compulsory
social insurance law, a rather extensive referee system has to be maintained.
Where the physician is paid fees for treating sickness of the insured, it
would be comparatively easy for the unscrupulous physician and insured
to run up a number of visits on the government and for the insured to
remain out of employment and receive the benefits of the insurance an
unnecessarily long time. In countries where physicians are paid a salary
on a capitation basis, a referee system is needed to see that the insured wage
earners do not take advantage of their privileges in calling on physicians
for inconsequential ailments, and to see that physicians, when called to a
case of sickness really needing attention, respond promptly.
As to the extent of social insurance, it may be said that some form of
it is in operation in every country of Europe, with the exception of Turkey.
In this country there is a considerable amount of optional, not compulsory,
social insurance carried on by fraternal orders and by commercial enter-
prises, as, for example, in this State by the Atlantic Coast Line Railroad.
Nine State governments have appointed commissions to study the subject
and to make recommendations to their general assemblies with respect to
action. The State of New York last year passed a compulsory social in-
surance bill in the Senate 30 to 20. The Governor supported the bill,
282 NORTH CAROLINA MEDICAL SOCIETY
but the lower house defeated it. The people of California, in 1918, held
a referendum on this issue, but defeated it about two to one. Many of
the State commissions appointed to study social insurance have recommended
some form of compulsory sickness insurance ; no State has yet adopted it.
Twenty-seven State Federations of Labor and twenty-six national trade
unions have endorsed it. The American Federation of Labor has a com-
mittee studying the subject. It is understood, however, that Mr. Gompers
and most of the labor leaders, John Mitchell of the United Mine Workers
of America excepted, are opposed to social insurance. Mr. Gompers and his
friends take the position that the wage earner should be paid enough so that
he wnll not be dependent upon the government in sickness. The National
Women's Trade Union League, the National Consumers' League, the
American Association for Labor Legislation, the Arnerican Hospital Asso-
ciation, the National Conference of Jewish Charities, and the National
Organization for Public Health Nursing have all endorsed the principle
of social insurance. It is interesting to know that the British Medical
Association, which almost called a strike in 1911 when the British social
law went into effect, recommended in 1916 that the act be extended, and
apparently the British Association, after five years' experience with com-
pulsory social insurance, are favorable to the principle. Mr. Lloyd George
has pointed out that the average physician's income has been increased under
the provisions of the British act $750 a year. The American Medical
Association, the State Health Officials and the American Public Health
Association are maintaining an open mind on this question. A considerable
amount of study is being given by these last named agencies to the subject.
Some very able committees representing the last named agencies are
making investigations and progress reports from time to time, but as yet
none of the agencies mentioned have committed themselves for or against.
The advantages of social insurance are : ( 1 ) it distributes the burden
of sickness and makes it, relatively speaking, easy to bear; (2) it does away
with pauperism to a large extent; (3) it does away with charity practice;
and (4) makes thrift compulsory. The disadvantage of social insurance,
especially in a democracy, is that it classifies people, economically speaking;
however, this is done by many of the laws that regulate taxes. Only cer-
tain persons pay income tax, and inheritance taxes, and the property tax is
imposed according to ability to pay. To my mind the advantages of social
insurance, or I will say some form of social insurance, outweigh its dis-
advantages; but I believe that, notwithstanding the many advantages, the
prospects for compulsory social insurance in North Carolina are rather
remote compared with the prospects of its getting a foothold in other sec-
tions of the country. Perhaps we shall have some form of social insurance
in North Carolina within ten years from now; perhaps a little earlier,
perhaps later. Now, the reasons for my saying that the movement will
be delayed in reaching North Carolina are: First, when compulsory social
insurance comes up in the South it will immediately become entangled with
the race problem ; the explanation is obvious- Second, when the matter
is proposed for serious consideration in North Carolina, we will have to
deal with the fact that compulsory social insurance has never been applied
to a class of the self-employed, to an agricultural population. It is a measure
designed for the wage-earning group, and so far in practice it has been
GENERAL SESSION 283
limited almost entirely to the wage-earning group. As we all know, North
Carolina is about 90 per cent agricultural.
' This question of social insurance is the biggest problem that concerns
the medical profession, individually and collectively. It is a question that
every physician should approach with an open mind and should carefully
study before reaching a conclusion. The trouble in England was that
the medical profession were unconcerned and took no interest in social in-
surance until the act was passed by the Government; then it was too late
for them to inform themselves thoroughly and for them to have the in-
fluence in shaping the legislation that they would have had and that they
should have had if they had waked up a little earlier.
I expect to see social insurance approach North Carolina in the form
of a law whidh will make optional with the county the right to levy a tax
for the care of sickness, to create a board to expend that tax in the construc-
tion and maintenance of hospitals and in the employment of a medical staff
properly apportioned as to specialists and paid by salaries rather than fees.
It is an interesting fact that as long as doctors are paid fees for sickness
it is to their business advantage, although in direct conflict with their pro-
fessional ideals, to have as much sickness as possible ; whereas, the very
minute the form of remuneration is changed from fees to salary and without
changing the total remuneration per year a single mill, you completely
reverse the business interest of the profession in sickness and make parallel
the direction of both the ph3^sician's business and professional interests. A
physician who hopes to collect $5,000 in fees in the present calendar year
is dependent for the realization of his hope upon the occurrence of sickness.
The same physician, paid a salary of $5,000 for taking care of the sick of a
certain district or town or class, is not dependent upon sickness and is tre-
mendously interested not only professionally, but as a business man, to see
that sickness is prevented. It is to the interest of the profession that their
interests, professional and business, should not be in conflict, as they are
under present conditions, but parallel, and society can bring about this con-
dition within the profession by changing not the amount of remuneration
of physicians, but its form, in substituting salaries for fees.
Dr. A. J. Crowell, Charlotte:
I think the Medical Society of the State of North Carol'na is to be
congratulated upon having at the head of its public health work a man
with such ideals and vision as Dr. Rankin. His efforts to prevent the
spread of disease are commendable. Dr. Rankin's ideals are one hundred
per cent efficient and have made for him a national reputation. North
Carolina stands at the head of the list in her efforts in prevention of the
spread of preventable diseases largely because of his vision and efforts-
We have in our midst this evening: another man who is interested in the
uplift of North Carolina along a different line, to whom I think we could
well afford to listen, for at least five minutes, and I move that Col. Leroy
Kirkpatrick be heard from on a subject in which he and the physicians of
North Carolina alike are vitally interested.
Dr. Crowell 's motion was seconded by Dr. Albert Anderson and passed.
Col. T. Leroy Kirkpatrick, Charlotte, N. C. :
I only ask five minutes of your time, to ask that you endorse a resolution
284 NORTH CAROLINA MEDICAL SOCIETY
in the interest of a State System of Hard-Surfaced Highways. I do not
make this request in my own behalf, but in the interest of the citizens of
North Carolina, ^
Next to medicine and the uplift of the health and the education of the
children of the Commonwealth, the construction of a State System of Hard-
Surfaced Highways is the biggest question before our people.
The movement for a modern system of State Highways has been endorsed
by every commercial body in North Carolina, by the newspapers, and by
a majority of the educational institutions of the State and by almost every
organized unit in North Carolina, and we feel sure of your endorsement.
I am not before you in behalf of my own selfish interest, but in the in-
terest of the present generation and generations unborn, and to ask the
most intelligent body in North Carolina to endorse this great movement.
North Carolina can pull herself out of the mud, because she has the
money to do it. Her total taxable resources approximate five billion
dollars; her banking resources four hundred million; her checking deposits
ninety-six million ; building and loans twenty-five million. Her citizens
hold in Government securities two hundred million. And from her total
resources from all crops last year approximated a billion and a half dollars.
We are first in the manufacture of raw cotton ; rank second as a manufac-
turing State in cotton goods ; we are fourth as an agricultural State and
twenty-third as a stock raising State.
The time has come when it is a disgrace to the good name of North
Carolina to have her citizens driving through mud that is hub deep. We
have a great western section of our State that is rich in natural resources
in the way of minerals and timber, as well as agricultural advantages- We
have a great east that offers as fine trucking facilities, because of the rich-
ness of the lands, as Florida. We have a great Piedmont section that
stands second as a manufacturing center. But one section of the State is
unacquainted with the other because we are not linked together by accessible,
rapid and cheap transportation system.
If we expect to sell North Carolina commercially, invite emigrants to
invest in our midst with their capital and become a part of us, we must put
the State in a position to compete with Virginia, which has just voted
sixty million dollars of bonds to build thirty-seven hundred and fifty males
of road. Maine has issued twelve million dollars of bonds; Maryland,
sixty million ; Illinois, sixtA^ million. Georgia is submitting a constitutional
amendment providing for fiftv million dollars of bonds. Kansas proposes
ten thousand and seven hundred miles of hard-surfaced roads ; Arkansas
has a hundred-million-dollar program, covering more than seven thousand
miles of road ; Missouri proposes a sixty million dollar bond issue ; Penn-
svlvania has voted one hundred and twenty-five million dollars of bonds;
Oklahoma, sixty million.
Now, North Carolina, religiously, agriculturally and industrially, cannot
enter into a friendly competition with these States without offering them,
through a State system of modern highways, like benefits.
Our North Carolina boys, through their patriotic efforts, gave a new
interpretation to the constitution and added a new halo of glory to the flag.
Many of them made the supreme sacrifice and broke the Hindenburg line.
GENERAL SESSION 285
But we, as yet, have not broken the line of sickness, the line of illiteracy or
the mud line, and the time has come to do it.
Dr. Cyrus Thompson, Jacksonville:
Mr. President, I neve^ like to talk on limited time. It is like fighting.
There is no particular objection to fighting except that you have to do so
much of it in such a little while, or it is not worth while to do anything.
I am interested in the matter of good roads, and I am going to introduce
directly a resolution, by request. I consented to introduce the resolution
because of the fact that I am interested in this subject.
I was sitting yesterday at dinner at the Rotary Club next to a man by
the name of Thomson. I said to him, "How do you spell your name?"
He said, "T-h-o-m-s-o-n." "Son of Thomas-" I said, "That is not mine."
He said, "It is the same name, isn't it?" "No," I said, "it is not the same.
My name is T-h-o-m-p-s-o-n, which was spelled originally Thompstone
or Thumpstone." Away back yonder, you see, my ancestors were interested
in good roads, perhaps from criminal necessity. They helped to break the
rocks to make hard roads, and so originated the "Thompson with a p."
Etymology and imagination assure me of this fact. I am not saying that
little about my original ancestors by way of detraction ; I don't suppose
that yours were any better than mine. You see all our ancestors were
bad — even the suffragette portion was bad; Adam testified to that. The
only thing that any of us have to pride ourselves on is that we are better
than our ancestors. We have made progress and are still making progress.
Let us hope that the best is yet to come.
Now, Colonel Kirkpatrick asked me to introduce this resolution, and I
have explained to you why I consented to do it:
"Be it Resolved:
FIRST: That the State Medical Society of North
Carolina, in meeting assembled, heartily endorse the con-
struction of a State Sj^stem of Modern Highways.
SECOND: We urge the members of the General
Assembly of North Carolina, when they meet in extra
session, to devise the necessary ways and means to build
a State System of Modern Highways. And that said
funds be equitably and impartially distributed to the
several counties of the State.
It is the sense of this meeting that a copy of this reso-
lution be forwarded by its secretary to Honorable T. W.
Bickett, Governor of Noth Carolina.
I do not see that we could hurt anything much by endorsing this. We
all want to make progress and have better roads.
I just wish to say a word about Dr. Rankin's paper, which is an im-
mensely progressive paper- He has in him a vision, a sort of idealism. He
senses the spirit of the times. The idea of progress is rampant all through
the world and we are coming on to new things. Whether we can get
something higher and better than what we have or shall go off the log in
one infernal crash, God Almighty knows. But we are getting away from
individualism the world over and getting toward socialism. There is a
286 NORTH CAROLINA MEDICAL SOCIETY
whole lot here and I would love to talk longer about it, but I cannot. A
simple suggestion in conclusion. When I was a young man, no campaign
was made in North Carolina that was not ridgepoled upon States' rights.
But you have not heard that doctrine in years until some fellow who did
not want women to vote brought up the question. This is a union, an
indissoluble union, of sovereign States, to be sure, but they are merged into
one union, the greatest commonwealth on earth.
I am going to stop ; but I wish I had time to run on a little longer.
Dr. M. Eugene Street, Glendon:
It is a great pleasure to me to see the State Medical Society, after
eighteen vears, take up the subject of Good Roads. B3. reference to the
Proceedings of the State Medical Society nt the Wrightsville meeting, 1902,
you will see that a paper on the subject was read there, the first paper on
this subject before this Society in all its history. The Society very enthu-
siastically wanted the author of that paper to go to the Legislature. From
that day to this I do not think there is any record of the Society's having
gone on record for good roads, but I do hope that it will unanimously so
go on record now.
Dr. Crowell:
Dr. Thompson read the resolution, but did not move its adoption. I
take great pleasure in' moving that the resolution be adopted.
This motion was seconded, and the resolution was adopted as read- After
this the session adjourned.
Thursday, April 22nd^ 11 A. M.
President, Dr. C. V. Reynolds, in chair.
The House of Delegates presented the report of the Nominating Com-
mittee, as adopted by it, for the approval of the General Session. (See
report of Nominating Committee to House of Delegates, pages 294 and
295).
In reporting the place of meeting for 1921 as Pinehurst, the House of
Delegates reported that the local medical profession in Moore County
would not be expected to furnish any entertainment. The time of meeting
Avas left to the discretion of the President and Secretary, in order that
satisfactory arrangements as to time could be made with the management
at Pinehurst.
On motion, the report from the House of Delegates was approved.
The President, Dr. Reynolds, requested Drs. J. F. Highsmith and I. W.
Faison to escort to the chair Dr. T. E. Anderson, President-elect. With a
few felicitous remarks, the retiring President inducted Dr. T. E. Anderson
into office.
Dr. T. E. ANDERSON:
To the Medical Society of the State of North Carolina:
Gentlemen : —
In accepting this distinguished honor which your kind indulgence has
placed upon me, I could wish that I had the gift of tongues to adequately
express my appreciation of it. These brave, true, noble men entrusted
with the obligation to make these selections, perhaps, have been governed
GENERAL SESSION 287
more by their brotherly feelings towards me than by their best judgment.
These were good men and, I think, fairly familiar with the Holy Scriptures,
but I fear they did not give the solemn scriptures due consideration, which
says: "There is a way which seemeth right unto a man, but the end thereof
is death." In the early days of air flying the papers alluded to those ven-
tures as "flirting with death."
The Methodist Episcopal Church has always boasted that they have never
made a mistake in the selection of their bishops. Up to this time that boast
might have been made by the North Carolina Medical Society, but the
future looks dark to me just now. However, the depth of my gratitude
must remain unspoken. It is said "Out of the abundance of the heart the
mouth speaketh." I wish that the heart had a language of its own, that
it might indulge in unrestrained flowing speech in acknowledgement of
this honor.
Some years past it was my great pleasure and fortune to stand in the
spacious Hall of the famed Ducal Palace at Old Venice and contemplate
this splendid and well preserved relic of Medieval Architecture and splen-
dor. Among the many things which hold the attention of the visitor is
the row of pictures of the Doges once directing her destinies arranged
around the upper walls, one frame only being vacant. This, it is explained,
was on account of the treachery and villainy of one of her citizens holding
this high place ; this vacant frame forever publishes his infamy. In the
Palace of the Memories of the members of the North Carolina Medical
Society, the frame allotted to me, enrolling me as one of your Presidents,
will not be vacant if a lifetime of love and devotion to all her ideals and
interests can place my image there-
I will simply conclude by telling you that this is an honor which I never
entertained in all my aspirations, because of a felt unfitness for it and that
there were many more deserving of it than I. Gentlemen— I thank you
most profoundly and ask your kind indulgence and help in discharging the
duties involved.
On motion of Dr. J. F. Highsmith, of Fayetteville, the appreciation and
thanks of the Medical Society of the State of North Carolina were ex-
tended to the Mecklenburg County Medical Society; to the Ladies' Enter-
atinment Committee, who made the stay of the visiting ladies so delightful ;
to the Committee on Arrangements, Dr. B. J. Witherspoon, the efficient
chairman, being included, as was also Dr. John Q. Myers, chairman of
the Hotel Committee ; and to the Masonic Order for the use of their mag-
nificent temple as a meeting place.
On motion of Dr. J. E. Brooks, of Blowing Rock, the thanks of the
Medical Society were tendered our retiring President, Dr. C. V. Reynolds,
for the efficiency, courtesy and kindness with which he had conducted the
proceedings of the convention.
At the first meeting of the new Board of Medical Examiners of North
Carolina the following officers were elected and the following subjects
assigned :
Anatomv and Embryology: Dr. L. A. Crowell, President, Lincolnton,
N. C. ■
288 NORTH CAROLINA MEDICAL SOCIETY
Obstetrics, Gynecology and Pediatrics: Dr. K. P. B. Bonner, Secretary-
Treasurer, Morehead City, N. C.
Chemistry, Hygiene and Physiology: Dr. W. M. Jones, Greensboro,
N. C.
Bacteriology, Histology and Pathology: Dr. C. A. Shore, Raleigh
N. C.
Materia Medica, Therapeutics and Pharmacology: Dr. J. G. Murphy
Wilmington, N. C.
Practice of Medicine : Dr. W. P. Holt, Duke, N. C.
Surgery: Dr. L. N. Glenn, Gastonia, N. C.
Proceedings of the House of Delegates
Tuesday, April 20th, 2:30 P. M.
The House of Delegates was called to order by the President, Dr. C. \
Reynolds. The roll of counties was called, and representatives answered
as follows:
Alamance, C. M. Walters; Alexander, (see Iredell-Alexander) ; Alle
ghany, not represented; Anson, not represented; Ashe, not represented;
Avery, W. B. Burleson ; Beaufort, S. T. Nicholson ; Bertie, not represented ^
Bladen, E. S. Clark; Brunswick, not represented; Buncombe, H. H. Brigga
D. E, Sevier and Thompson Frazer; Burke, I. M. Taylor; Cabarrus, not
represented; Caldwell, A. B. Goodman; Camden, (see Pasquotank-Camden-
Dare) ; Carteret, K. P. B. Bonner; Caswell, not represented; Catawba^
not represented; Chatham, not represented; Cherokee, N. B. Adams;
Chowen-Perquimans, J. S. Mitchener; Clay, (see Macon-Clay) ; Cleveland,
E. B. Lattimore ; Columbus, not represented ; Craven, not represented ;
Cumberland, J. F. Highsmith; Currituck, not represented; Dare, (see
Pasquotank-Camden-Dare); Davidson, C. A. Julian; Davie, not repre-
sented ; Duplin, John W. Carroll ; Durham-Orange, B. W. Fassett and Foy
Roberson ; Edgecombe, C. L. Outland ; Forsyth, D. L. Dalton ; Franklin,
S. P. Burt; Gaston, James A. Anderson; Gates, not represented; Graham,
not represented ; Granville, not represented ; Greene, John L. Carroll ; Guil-
ford, John W. Long, J. T. Burrus and D. A. Stanton; Halifax, P. C.
Carter; Harnett, W. P. Holt; Haywood, J. Howell Way; Henderson-
Polk, not represented; Hertford, not represented; Hoke, L. B. McBrayer;
Hyde, not represented; Iredell-Alexander, M, R. Adams; Jackson, not
represented; Johnston, not represented; Jones, not represented; Lee, W. A.
Monroe; Lenoir, W. F. Hargrove; Lincoln, W. F. Elliott; Macon-Clay,
S. H. Lyle; Madison, W. A. Sams; Martin, B. L. Long; McDowell, J. F.
Jonas ; Mecklenburg, B. J. Witherspoon ; J. E. S. Davidson, R. Z. Linney,
and L. W. Hovis ; Mitchell-Watauga, C. E. Smath ; Montgomery, not
represented; Moore, M. Eugene Street; Nash, not represented; New Han-
over, J. G. Murphy ; Northampton, L. E. McDaniel ; Onslow, Cyrus
Thompson; Orange, (see Durham-Orange); Pamlico, not represented;
Pasquotank-Camden-Dare, R. L. Kendrick ; Pender, not represented ; Per-
quimans, (see Chowan-Perquimans) ; Person, not represented; Pitt, Chas.
O'H. Laughinghouse ; Polk, (see Henderson-Polk) ; Randolph. T. I. Fox;
Richmond, not represented; Robeson, W. E. Evans; Rockingham, J. B.
Ray; Rowan, J. L. Monk; Rutherford, D. R. Schenck ; Sampson, G. L.
Sikes ; Scotland, not represented ; Stanly, not represented ; Stokes, R. G-
Tuttle; Surry, J. B. Smith; Swain, A. M. Bennett; Transylvania, not rep-
resented; Tyrell, (see Washington-Tyrell) ; Union, S. A. Stevens; Vance,
not represented ; Wake, T. M. Jordan and J. B. Wright ; Warren,
not represented; Washington-Tyrell, Joseph L. Spruill ; Watauga, (see'
Mitchell-Watauga) ; Wayne, not represented; Wilkes, J. E. Duncan,
C. S. Sink, alternate ; Wilson, K. C. Moore ; Yadkin, not represented ;
Yancey, J. B. Gibbs-
The Secretary read his report. On motion, the same was accepted and
the financial part was referred to the Finance Committee.
290 NORTH CAROLINA MEDICAL SOCIETY
REPORT OF THE SECREARY-TREASURER TO THE
MEDICAL SOCIETY OF THE SI ATE OF NORTH CAROLINA.
Early following the close of the last session the Secretary notified all
officers and committees of their appointment. He has also notified com-
mittees that were to report to this session.
MEMBERSHIP.
On page 302, Transactions for 1919, we estimated in our report of one
year ago that we would probably be able to get 1,200 paid-up members.
The record shows that we had 1,213 plus 93 Honorary Fellows — 1,306
members, the largest number by a few of any year in the history of the
Society. We have today 1,115 paid-up members, which number plus the
Honorary Fellows gives us 1,217 members. This is the largest paid-up
membership by far that we have ever had at the convening of the Society.
This is an indication, I take it, that a goodly number of doctors in North
Carolina are taking more interest in the organized medical profession. We
are hoping that we may add at least 200 more names to this roster before
the Transactions go to press, and we certainly ought to have 500. May
we express the hope that at least a few influential men in each county will
interest themselves sufficiently to get the doctors in their county now out
to come into their county society. The Secretary will be writing you about
it when this meeting is over.
IN REGARD TO FINANCES.
You will find appended hereto the report of the Treasurer. You will
note that all bills have been paid, except for printing program, which state-
ment has not yet been received. You will note that the bank statement
shows a balance of $1,565.92 as against $564-34 last year, an increase of
one thousand dollars over last year. Part of this, however, is taken up in
the larger percentage of members in good standing.
As mentioned last year, we are gradually reducing our deficit. After a
careful study of our assets and liabilities, we find that we can probably
reduce our deficit by about $300 annually, provided we do not increase
our expenses. You will no doubt be pleased to learn that our deficit now
does not give us any particular trouble, for the reason that try hard as we
can, we cannot get the printer to give us the Transactions until well along
in the winter, contracts to the contrary notwithstanding. So that the dues
for the succeeding year enable us to finish paying for the Transactions with-
out a great deal of delay and without becoming liable for interest charge.
CORRESPONDENCE
The correspondence is necessarily large. We feel today that we ought
to have done more. We feel that the officers and councilors could even
do more than we have been doing if we kept in closer touch with the doctors
of the State, members and non-members. We have sent out from the office
986 personal letters and 9,354 multigraph or printed letters, some of these
letters without expense to the Society for postgge.
DELINQUENT COUNTY SOCIETIES.
The following societies have not reported or paid dues for their members
for 1920: Burke, Chowan-Perquimans, Craven, Gaston, Macon-Clay,
PROCEEDINGS OF THE HOUSE OF DELEGATES 291
Montgomery, Rockingham, Scotland, Swain, Transylvania, Yadkin. This
represents 11 societies and 109 members as per last year's report. We take
it that these 11 counties are not entitled to representation in the House of
Delegates, nor are any physicians resident in these counties entitled to hold
any office in the gift of this Society. (See Chapter 1, Section II, and
Chapter 11, Sections I and II, By-Laws.)
PROGRAM.
No doubt the program will commend itself to you as one among the best
presented to this Society. I desire to say that the chairmen of sections are
entirely responsible for the same, and are due the thanks of the officers and
members of our Society.
All of which is respectfully submitted.
(Signed) L. B. McBRAYER,
Acting Secretary-Treasurer.
April 16, 1920.
TREASURER'S REPORT.
April 12, 1919, to January 1, 1920.
Balance April 12, 1919, as per statement in Transactions, p. 304 $ 564.34
Dues 1,159.50
Total Receipts $1,723.84
ITEMIZED DISBURSEMENTS
April 12, 1919, to January 1, 1920.
Check No.
17 Western Union T. Co. (telegrams) $ 2.65
18 Dr. T. W. Shore (refund dues) 3-00
19 Western Union T. Co. (telegrams) 7.85
20 J. T. Jerome (rent moving picture Pinehurst) 9.50
21 Void
22 Miss Mary Robinson (reporting meeting) 49.98
23 Commercial Printing Co. (program) 163.50
24 Western Union T. Co. (telegrams) .81
25 Western Union T. Co. (telegrams) 10.02
26 Dr. J. L. Ransom (refund dues) 3.00
27 Dr. J. T. J. Battle (excess dues returned) .50
28 Mrs. T. W. Adickes (reporting meeting) 59.61
29 Dr. R. C. Matheson (refund dues) 3.00
30 Dr. B. B. Lloyd (refund dues) 3.00
31 Mrs. M. L. Murrav (reporting meeting) 68.29
32 Dr. W. L. Dunn ('refund dues) 3.00
33 Mrs. T. W. Adickes (reporting meeting) 53.73
34 Dr. C. W. Cocke (refund dues) 3.00
35 Miss Mary Robinson (reporting meeting) , 84.40
36 Edwards & Broughton (reprint President's address) 98.15
37 Miss Mary Robinson (reporting meeting) 48.07
38 Mr. T. B. Eldridge (proof reading) 22.50
39 Edwards & Broughton (acct. Transactions) 1000.00
TOTAL $1697.56
Balance January 1, 1920 $ 26.28
292 NORTH CAROLINA MEDICAL SOCIETY
TREASURER'S REPORT.
Jan. 1, 1920, to April 16, 1920.
Balance from 1919 $ 26.28
Interest on $1000.00 from April 24, 1919, to Jan. 1, 1920 26.67
Dues : 3478.00
Total Receipts $3530.95
ITEMIZED DISBURSEMENTS
Jan. 1, 1920, to April 16, 1920.
Check No.
40 Western Union T. Co. (telegrams) $ 1.41
41 Dr. J. H. Harper (refund dues) 3.00
42 Commercial Printing Co. (secretaries' reports) 23.50
43 Edwards & Broughton (Transactions) 522.27
44 Void
45 Edwards & Broughton (Transactions) 601.01
46 Void
47 Postmaster (stamps) 127.41
48 Dr. L. B. McBrayer (salary Sec.-Treas.) 600.00
49 A. W. Snow (clerical help) 25.00
50 Letitia Thorpe (clerical help) 10.00
51 L. Mayhew (clerical help) 10.00
52 Dr. Turner (refund dues) 3.00
53 Commercial Printing Co. (announcements) 12.23
54 Dr. Paul G. Parker (refund dues) 3.00
55 Western Union T. Co. (telegrams) 20.20
56 Dr. A. S. Jones (refund dues) 3.00
Total $1965.03
Balance April 16, 1920 (on deposit with Page Trust Co.) $1565.92
Burke County not having made a report, Dr. I. M. Taylor, Honorary
Fellow, being present, on motion was allowed to stand good for five mem-
bers from his Society and was seated as a delegate.
Dr. Charles O'H. Laughinghouse reported for the committee on Mid-
wives. Report as follows:
REPORT OF COMMITTEE ON REGULATION OF WORK OF
MIDWIVES.
Your Committee finds that the midwives are in attendance at 30,000
of the 80.000 births that occur annually in North Carolina.
Your Committee is of the opinion that under present conditions it is im-
practicable, as well as impossible, for the State to prohibit attendance on
obstetrical cases by midwives. Your Committee believes that because of
extensive interest now shown by many States in the form of proposed
/tgislation for maternity benefits and care, that in no distant time pregnancy
and obstetrics will be accepted as a public responsibility and care
at least to a limited extent, and that when this public recognition of the
PROCEEDINGS OF THE HOUSE OF DELEGATES 293
necessity of better professional service for pregnancy and obstetrics arrives,
the problem of midwifery will be effectively solved-
Under present conditions your Committee recommends:
(l)That the North Carolina State Board of Health shall prepare, or
have prepared, and published a simple primer on midwifery for the use of
midwives.
(2) That the State Board of Health prepare a standard county regula-
tion for the control of midwives, for adoption by counties, with the effect
of law, as provided for in section 9, chapter 62, Public Laws of 1911, as
amended.
(3 ) That the regulations above mentioned require that midwives be given
a permit when they are able to stand a successful examination on the afore-
mentioned primer, to be given by the whole-time county health officer or
nurse.
(4) That the aforesaid permit be a conditional permit, conditioned: (a)
upon the midwife's compliance with the State laws relating to the practice
of midwifery; (b) that the midwife shall refrain from making vaginal ex-
aminations; (c) that the midwife decline to attend and that she refer to
registered physicians, when the information is in her possession in time to
do so, the following kind of cases: (1) cases of pregnancy or obstetrics that
have suffered considerably with premonitory symptoms of eclampsia, as
stated in the primer; (2) cases of pregnancy with a history of difficult
labors; (3) cases of pregnancy or obstetrics with collapsed parts or ab-
normal positions.
On motion report was adopted.
The Committee on Single Examining Board was continued.
Dr. J. E. S. Davidson moved that the Secretary be instructed not to print
the Transactions of the State Health Officers' Association in the Transac-
tions of the Medical Societ}'. After remarks by Drs. Cyrus Thompson,
I. M. Taylor and Charles O'H. Laughinghouse, Dr. Thompson moved
to lay the motion on the table, which was seconded by Dr. J. Howell Way
and carried unanimously.
Dr. J. W. Long moved that Dr. J. B. Councill of Salisbury be placed
^n the roster of Honorary Fellows; motion to lay on the table, carried.
Dr. J. W. Long moved that a committee be appointed to look into and
report on the status of Dr. J. B. Councill. Carri